THE LIBRARY 
 OF 
 
 THE UNIVERSITY 
 
 OF CALIFORNIA 
 
 LOS ANGELES 
 
 GIFT 
 
 r, and Mrs, 'jI, Libby
 
 w 

 
 RHEUMATISM, 
 
 RHEUMATIC GOUT, AND SCIATICA
 
 " RHEUMATISMUS SI MINUS PERITE TRACTETUR, NON AD 
 MENSES TANTUM, SED AD ANNOS ETIAM ALIQUOT, IMMO PER 
 OMNEM ADEO VITAM, MISERUM HAUD INFREQUENTER DIS- 
 CRUCIAT." 
 
 Sydenhami Opera, Cap. V, sect. vi.
 
 ON 
 
 RHEUMATISM, 
 
 EHEUMATIC GOUT, AND SCIATICA, 
 
 PATHOLOGY, SYMPTOMS, AND TREATMENT. 
 
 HENRY WILLIAM FULLER, M.D. Cantab., 
 
 FELLOW OF THE ROYAL COLLEGE OF PHTSIOIANS, LONDON j PHYSICIAN TO ST. GEORGE'i 
 HOSPITAL, ETC., ETC. 
 
 Jtom the ta;st l^ondon ©ditioit. 
 
 PHILADELPHIA: 
 LINDSAY & BLAKISTON 
 
 1864.
 
 IIKNUY n. ASIIMEAD. PRINTER,
 
 W£ 
 
 PREFACE TO THE THIRD EDITION. 
 
 The demand which has arisen for a Third Edition of 
 this Treatise induces me to hope that my researches into 
 the nature of Rheumatism and Rheumatic Gout, and my 
 efforts to introduce a successful method of treatment have 
 not been wholly unavailing. Encouraged by this feeling, 
 I have endeavored to render the work as complete and 
 useful as possible, by bestowing more than ordinary care 
 on its revision, by adding many practical suggestions, and 
 by carefully recording the result of my experience as 
 to the action of remedies which have been recently 
 introduced. 
 
 The time which has elapsed since I first broached my 
 opinions on the subject of Acute Rheumatism has enabled 
 me to estimate at its true value the method of treatment 
 which I then proposed ; and I have much satisfaction in 
 being enabled to affirm that the statements formerly 
 made as to its efficacy have been more than verified. It 
 subdues the pain and inflammation within a few^ days, 
 and if vigorously carried out, completely protects the 
 heart from mischief. 
 
 My views as to the nature of Rheumatic Gout, and its
 
 vl PREFACE. 
 
 entire independence of Gout and Rheumatism, have re- 
 ceived confirmation from the published researches of 
 Adams, Garrod, and others, and it only remains for me 
 to state that extended observation has led me to believe 
 that, if properly managed, this disease is far less obsti- 
 nate and formidable than it has appeared to be under the 
 ordinary methods of treatment. 
 
 On the subject of Chronic Rheumatism, much still 
 remains to be ascertained ; for I am satisfied that many 
 maladies are included under that comprehensive title 
 which have nothing more in common than have small- 
 pox and chicken-pox. I have endeavored, however, as 
 far as possible, to separate the different varieties, and to 
 point out the remedies to which each is most amenable. 
 
 In the chapter on Sciatica and Neuralgic Rheumatism, 
 I have given the result of my experience as to the effect 
 of injecting morphia into the cellular tissue, and have also 
 specified the conditions under which galvanism, elec- 
 tricity, and other remedies, prove useful. I have also 
 appended a few cases illustrative of the treatment 
 recommended. 
 
 My friends have urged me to add a chapter on Gout, 
 as being an important member of the family of diseases 
 comprehended in the scope of the present inquiry. But 
 it would add so greatly to the bulk of this book, that I 
 have determined to reserve my remarks on the subject 
 for a separate volume.
 
 PREFACE TO THE FIRST EDITION. 
 
 Above two thousand years ago, Hippocrates laid down 
 the maxim, that all theories should be framed xara f^vsw 
 Siuf^Mv. From that time to the present, this maxim has 
 prevailed in many departments of medical science ; but 
 in the investigation of rheumatism it has been too often 
 neglected. Cold, and inflammation consequent thereon, 
 have been regarded as the beginning and end of the 
 disease ; and any facts militating against this doctrine 
 have been heedlessly passed by or pronounced of little 
 moment. So that, in the words of Professor Whewell, 
 "the subjects of attention have not been external objects, 
 but speculations previously delivered ; the object has not 
 been to interpret nature, but man's mind ; the opinions 
 of the masters are the facts which the disciples have 
 endeavored to reduce to unity, or to follow into con- 
 sequences."^ 
 
 With the view of avoiding this source of error, I had 
 proposed to myself to commence the present Treatise by 
 a faithful record of all that has been ascertained of the 
 history of rheumatism ; and by reference to the facts 
 
 ^ Whewell's " Inductive Sciences," vol. i, p. 18.
 
 Viil PREFACE. 
 
 thus proved and established, to show how conflicting opin- 
 ions may be reconciled, and the pathology and treatment 
 of the disease elucidated. The reader would thus have 
 been impressed at the outset with many of those striking 
 facts which serve as exponents of the true nature of the 
 disorder, and would have been enabled to estimate the 
 force of any argument opposed to his preconceived opin- 
 ions. But so many obstacles presented themselves to 
 this arrangement, that I determined to commence at once, 
 by a full exposition of my views of the disorder, and by 
 constant reference to established facts, to counteract, as 
 far as possible, those sources of uncertainty which, under 
 this arrangement, might otherwise have presented them- 
 selves. Nothing but a firm conviction of the necessity 
 for a full recognition of the true nature of the disease, 
 with a view to its scientific and successful treatment, 
 could have induced me to enter so fully as I have done 
 into the various circumstances which bear upon this 
 important question ; and if such details appear out of 
 place in a treatise intended to be purely practical, their 
 insertion will, I trust, be excused, on account of the 
 information they allbrd to the Physiologist. 
 
 The space allotted to those diseases of the Heart which 
 arise so frequently in connection with Rheumatism, may, 
 at first sight, appear unnecessarily large. But the im- 
 portance of these affections cannot be over-estimated. 
 They may complicate and render formidable the simplest 
 case of Rheumatism, and may affect the future as well
 
 PREFACE. IX 
 
 as the present safety of the patient ; moreover, they are 
 the very points on which the Student is most in need of 
 instruction and advice. Their incursion is often insidious, 
 their progress rapid ; and he who is not well informed on 
 all that relates to their symptoms and treatment, may 
 often overlook their existence, and fail to avert their most 
 dangerous consequences. I have therefore been unwilling 
 to omit anything which may lead to a just estimate of 
 their importance, to a full understanding of their physical 
 signs and symptoms, and to a due appreciation of the 
 various grounds on which their treatment should be 
 based. 
 
 I have availed myself of the labors of my predecessors, 
 wherever their views have appeared to me correct ; and 
 have uniformly acknowledged the source and extent of 
 my obligation. Where, as on some points, I differ from 
 those for whose judgment and experience I have the 
 greatest regard, I have not hesitated to avow it, and to 
 point out the grounds of my opinion. In so doing, I have 
 strictly adhered to facts, and believe I have stated 
 nothing which will not be confirmed hy more extended 
 inquiries. 
 
 To my colleague and former teacher. Dr. J. A. Wilson, 
 Senior Physician to St. George's Hospital, I am indebted 
 for having first awakened my mind to the necessity for 
 a complete and searching investigation into the source, 
 nature, and treatment of Rheumatism, as also for allow- 
 ing me to test the respective merits of topical ap])lications
 
 X PREFACE. 
 
 in several well-marked cases. To my friend and colleague, 
 Dr. Bence Jones, my best thanks are due, for his uniform 
 kindness in affording me opportunities of treating the 
 disease in its more acute and terrible form : I am also 
 indebted to Dr. Blackall, Senior Physician to the 
 Dreadnought Hospital Ship ; to Dr. Fincham, formerly 
 Physician to the Pimlico Dispensary ; and to several other 
 of my friends, for opportunities of treating the disease, or 
 of witnessing the eflect of treatment. 
 
 How far the conclusions at which I have arrived will 
 be confirmed by further experience, time alone can decide, 
 but the labor I have bestowed upon the investigation 
 will not have been thrown away, if it has enabled me to 
 make some little addition to our slender stock of knowl- 
 edge on this important and fearful disease.
 
 PREFACE TO THE SECOND EDITION. 
 
 The favorable reception accorded to this work by my 
 professional brethren in England, as also in America, 
 where it has been reprinted, has encouraged me to 
 undertake its complete revision, preparatory to the issue 
 of a second edition. Errors have been corrected, omis- 
 sions supplied, and whatever appeared to need further 
 elucidation has been carefully rewritten, or more fully 
 explained. Throughout the work, but especially in the 
 chapters on Rheumatic Gout, Chronic Rheumatism, and 
 Sciatica, much additional matter has been inserted, which, 
 as founded on a large number of personal observations, 
 backed by communications received from medical men in 
 various parts of the world, will be found, I believe, of 
 practical value. 
 
 My views in regard to the treatment of the acute 
 disease have not undergone any essential modification 
 since the year 1845, when I first had recourse to full and 
 repeated doses of alkalies and the neutral salts, and I am 
 glad to find that Dr. Garrod and many others, who, within 
 the last four years, have made trial of these remedies in 
 the cure of Rheumatism, have confirmed, to the letter, 
 the statements made in the first edition of this work.
 
 xii PREFACE. 
 
 It, will be a further satisfaction to learn that the sug- 
 gestions thrown out in tlie present edition, relative to the 
 successful treatment of certam chronic forms of the dis- 
 ease, are as fully borne out by the experience of others ; 
 and I shall deem it an especial favor if those persons 
 whose opportunities enable them to throw any light on 
 the subject, will kindly favor me with the result of their 
 observations. 
 
 I
 
 CONTENTS. 
 
 CHAPTER I. 
 
 INTRODUCTION. 
 
 PAGE 
 
 Rheumatism deserving of attentive study ...... 25 
 
 Commonly supposed to be attributable to cold. Not so in reality . . 25 
 General and local effects of cold as ascertained by observation and 
 
 experiment ........... 27 
 
 Rheumatism sometimes ascribed to the combined influence of cold and 
 
 moisture. Objections to this theory ...... 29 
 
 Probably due to the presence of a morbid matter in the blood. Argu- 
 ments in fixvor of this doctrine . . . . . . . .32 
 
 Source of this morbid matter. Facts in support of its being a product of 
 
 malassimilation, or vicious metamorphic action . . . .36 
 
 Nature of the poison. Probably lactic acid ...... 40 
 
 Specific character of the poison ........ 42 
 
 Predisposing and exciting causes of rheumatism . . . . .44 
 
 Recapitulation and views of author as to the action of the rheumatic 
 
 virus 47 
 
 CHAPTER n. 
 
 ON THB RHEUMATIC DIATHESIS, AND THE CAUSES WHICH INFLUENCE ITS 
 DEVELOPMENT. 
 
 Circumstances which favor the development of rheumatism . . .49 
 The hereditary character of rheumatism. Statistical observations on this 
 
 subject . . . . . . . . . . . .51 
 
 Age at which the disease usually appears 58 
 
 Form which it assumes at different ages .59 
 
 An acute attack does not strengthen the disposition to the disease . . 59 
 The class of persons and the sex most liable to its attacks . . . 59 
 The effect of climate and season on its production . . . . .60 
 Statistical Reports on these subjects 60
 
 xiv CONTENTS. 
 
 CHAPTER III. 
 
 ON THE SEAT OF RHEUMATISM, AND THE CLASSIFICATION OF ITS DIFFERENT 
 
 VARIETIES. 
 
 PAOB 
 
 Differences of opinion as to the seat of rheumatism . . . .61 
 
 All parts of the body liable to suffer . t3l 
 
 The white fibrous tissue throughout the body especially liable to be 
 
 attacked . 63 
 
 Probable explanation of this fact ........ 64 
 
 Those joints which are most exposed or most exercised, and those which 
 at any time have been subjected to injury, are peculiarly obnoxious 
 
 to an attack 64 
 
 Probable explanation of this circumstance ...... 65 
 
 The local symptoms assume a symmetrical arrangement . . . .66 
 
 Classification of rheumatism ......... 67 
 
 Chief characteristics of its different varieties .68 
 
 CHAPTER IV. 
 
 ON ACCTB BHECMATISM, OR RHEUMATIC FEVER. 
 
 Acute rheumatism, or rheumatic fever. Its extreme danger . . .70 
 Age at which it occurs. Its various modes of attack . . . .70 
 
 Its symptoms, general and local . . . . . . . .71 
 
 The fever not commensurate with the extent and intensity of the articular 
 
 inflammation ........... 75 
 
 The perspiration often spoken of as "enfeebling and useless." Not so in 
 
 reality 77 
 
 Symptoms indicative of a subsidence of the disease . . . .79 
 
 The stiffness which remains after the subsidence of the acute disease, not 
 
 to be mistaken for a chronic form of the disorder . . . .80 
 Duration of an attack of acute rheumatism under ordinary methods of 
 
 treatment. Opinions of different authors as to its duration . . 80 
 
 Statistical Report on the subject 84 
 
 Can the paroxysm be immediately arrested or cut short by ordinary tJ-eat- 
 ment? Grounds for author's opinion to the contrary, and explana- 
 tion of the cases which are often cited in proof of such an occur- 
 rence . . . . . . . . . . . .81 
 
 Result of author's treatment on the duration of the disease . . .81 
 Various complications of the disease. Their severity and importance . 83
 
 CONTENTS. XV 
 
 CHAPTER V. 
 
 ON THE TREATMENT OF ACITE RHEUMATISM, OR RHEUMATIC FEVER. 
 
 PAGE 
 
 Various kinds of remedies have been employed. Treatment hitherto 
 
 uncertain and contradictory. Cause of this uncertainty . . 85 
 
 Grounds on which the rational treatment of acute rheumatism should be 
 
 based, and objects to be effected 86 
 
 Means of fulfilling them . 87 
 
 Value of different remedies : 
 
 Bleeding. — When and to what extent to be employed. Danger which 
 
 attends its injudicious use . ..... 88 
 
 " Buffing and cupping of the blood not an indication for its repe- 
 tition 92 
 
 " Opinions of various physicians as to its efficacy ... 92 
 
 Purging. — When and to what extent advisable. Cautions to be observed 
 
 in its employment ........ 94 
 
 Opium. — Ordinary mode of administration inefficient. Dr. Corrigan's 
 method of treatment by. Result of author's experience, 
 with suggestions as to the value of the remedy in full and 
 repeated doses . . . . . . . .97 
 
 Vapor and Eot-Air Baths. — Usually unnecessary in the acute stage of 
 
 the disease. Under what circumstances to be employed. 100 
 
 Mercury. — If given so as to affect the mouth ahnost always prejudicial. 
 
 When and how to be administered ..... 101 
 
 Tartar Emetic. — Laennec's opinion in regard to. To be employed as an 
 
 adjunct to other remedies . . . . . .102 
 
 Cinchona. — Dr. Haygarth's method of administration. Usually dangerous 
 in the active stage of the disease. When and in what doses 
 to be made use of . . . . . . . .103 
 
 Colchicum. — Its curative power. Its poisonous effects. Class of cases in 
 which it is most strikingly beneficial. Cautions to be ob- 
 served in its administration . . . . . .104 
 
 Guaiacum. — Dr. Seymour's report as to its modus operandi. Result of 
 author's observation as to its curative powers. How and 
 when to be employed 106 
 
 Nitrate of Potash. — Report of various physicians as to the action of. 
 
 Author's opinion as to its efficacy ..... 107 
 
 Lemon-Juice. — Effect attributed to it by Dr. Owen Rees. Usually ineffi- 
 cacious. Average duration of the disease under this treat- 
 ment 109 
 
 Alkalies and their Salts. — Their exceeding value in acute rheumatism. 
 Inoperative in ordinary doses, and why. Inadequate to 
 effect a speedy cure when unassisted by other remedies . Ill 
 
 In the treatment of acule rheumatism each remedy, or class of remedies, 
 
 has been too exclusively relied upon . . . . . .112
 
 XVI 
 
 CONTENTS. 
 
 Author's method of treatment. Its ratiouale. Success which has 
 
 attended it 115 
 
 Value of topical applications as adjuncts to the general treatment . 118 
 Experiments to prove the relative value of different topical applications 119 
 Experiments tending to prove that articular inflammation may be in some 
 
 measure prevented by judicious fomentations . . . .119 
 General rules for the diet during an acute attack . . . . .120 
 Cases in illustration of the treatment to be pursued . . . .120 
 Remarks on the effect of the treatment in the above cases . . . 132 
 Observations on the effect of the treatment in several other cases . 1 34 
 
 CHAPTER YI. 
 
 ON THE CAU.SES OF RHEUMATIC AFFECTION OF THE HEART. 
 
 Rheumatic affection of the heart long unknown and unsuspected . 
 Now recognized as imparting to acute rheumatism its chief danger 
 Not generally due to metastasis ........ 
 
 Information respecting the cause of their occurrence to be gleaned from 
 
 an inquiry into the causes which determine rheumatic arthritis 
 Treatment most effectual in preventing the access of cardiac inflamma- 
 tion ............ 
 
 Inflammation not the only form of heart disease which occurs in con- 
 nection with rheumatism. ........ 
 
 Grounds of this opinion: 
 
 Evidence derived from the symptoms during life 
 " " post-mortem examinations 
 
 " " actual experiment 
 
 " " the condition of the blood 
 
 " " the difference in the frequency of 
 
 " " CO current pulmonary inflamma- 
 
 " " tion in different forms of rheumatic 
 
 " heart affection 
 
 Ohjcctions to this opinion answered ....... 
 
 Practical hints to be derived from this view of the subject 
 Summary of author's views respecting the occurrence of rheumatic in- 
 flammation of the heart ... 
 Summary of author's views respecting the occurrence of fibrinous deposi 
 tion on the endocardium 
 
 137 
 137 
 138 
 
 139 
 
 144 
 
 145 
 
 j- 145-150 
 
 150 
 152 
 
 153 
 
 154
 
 CONTENTS. XVU 
 
 CHAPTER VIT. 
 
 RHEUMATIC INFLAMMATION OP THE HEART ITS PATHOLOGICAL EFFECTS — ITS 
 
 SYMPTOMS, PUOGHESS, AND TERMINATIONS. 
 
 PAGE 
 
 Anatomical character of the pericardium*: nature of, and products result- 
 ing from, the inflammation to which it is subject. Influence which 
 the mechanism of the pericardium exerts on the progress and term- 
 ination of pericarditis . . . . . . . . .156 
 
 Terminations of pericarditis. Pathological effects observed when the 
 disease terminates favorably, and also when unfavorably. Condition 
 of the parts varies greatly according to the period which has elapsed 
 since the commencement of inflammation ..... 157 
 
 Pericardium, when once inflamed, rarely restored to the condition of 
 
 health 159 
 
 Pathological changes produced by endocarditis. Where chiefly observed 161 
 The appearances presented by fibrinous vegetations vary in different 
 
 cases, and at different stages of their existence . . . .162 
 
 Result of the microscopic examination of fibrinous vegetations . . 163 
 Consecutive changes Avhich follow the deposition of fibrin on the valves 164 
 Comparative danger of pericarditis and endocarditis, and the conse- 
 quences to which tliey give rise ....... 1G5 
 
 Possibility of complete recovery after an attack of endocarditis . . ]G7 
 Great improbability of complete recovery when fibrinous deposits have 
 
 taken place on the valves, and why IGf) 
 
 Physical signs of pericarditis. 
 
 Friction-sound. Referable to the altered mechanism of the 
 parts. Its extreme value as a diagnostic sign. Two different 
 causes of its cessation . . . . . . .17(1 
 
 Pra^cordial dullness. Not pathognomonic of effusion, but valua- 
 ble as an accessory symptom of pericarditis, and as indicating 
 the increase or decrease of effusion . . . . .172 
 
 Friction thrill. Its usual position. Under what circumstances 
 
 present 174 
 
 Undulation. Does not always exist, and why . . . 175 
 Practical inferences to be deduced from these signs, more especially in 
 
 reference to the nature of the prognosis 175 
 
 Physical signs of endocarditis. 
 
 Bellows-murmur. Referable to the altered mechanism of the 
 
 valves, and how 177 
 
 " " Mode of distinguishing disease of the differ- 
 ent valves 17,S 
 
 " " Difficulties whicli occasionally present them- 
 
 selves in forming a diagnosis. How to 
 be overcome ...... 182
 
 will 
 
 CONTENTS. 
 
 Goiicral syniptonis of rheumatic carditis. Usually more marked in cases 
 of pericarditis than in cases of endocarditis. In some instances 
 characteristic : in some altogether absent. To be valued accordingly 184 
 
 Head symptoms, when occurring in the course of acute rheumatism, 
 usually symptomatic of cardiac inflammation .... 
 
 Resume of the principal facts relating to rheumatic inflammation of the 
 heart, with hints as to the prognosi.s in diff'erent cases 
 
 Abstract of 16 fatal cases of acute rheumatism, with a record of the ap- 
 
 jioarances found on dis^^ection ....... IRO 
 
 186 
 
 188 
 
 CHAPTER VIII. 
 
 U.S tin: TRK.\T.\1KNT OT 1IIIEU.\I.\TIC 1NKL.\M.\1 ATION OF THE HE.\KT. 
 
 Chief i)0ints for consideration in reference to rheumatic inflammation of 
 
 the heart 204 
 
 Calomel given so as to affect the system considered by some persons to 
 
 be a safeguard for the heart. Not so in reality .... 20'' 
 
 Those remedies only can assist in preserving the heart from mischief 
 which have the power of warding ofl", or arresting, an attack of rheu- 
 matism ............ 20G 
 
 I'athological conditions to be attended to in the treatment of rheumatic 
 
 cardiac inflammation 207 
 
 Venesection. When, and how far serviceable ..... 20D 
 
 Local blood-letting often useful. Leeching, when to be employed, and 
 
 when cupping . ......... 210 
 
 .Mercury. Its action in rheumatic carditis. How to l)e administered. 
 Its effects sometimes difllcult to obtain. When most beneficial. 
 When prejudicial to the patient's safety . . .211 
 
 Opium. Its inestimable value in these cases. Suggestion as to whether 
 
 it may not exercise some directly curative influence . . . 21.'> 
 Rlisters. Always useful. When most efiicient ..... 217 
 
 Alkalies, colchicum, and diuretics, most important remedies . . .217 
 Rest and abstinence of the utmost consequence . . . . .217 
 
 .Symptoms which justify the commencement of active treatment , . . 218 
 Caution to be observed in watching for any mischief .about the heart, 
 
 even during the patient's convalescence ...... 221 
 
 Treatment to be .adopted, when much irritability of the heart remains 222 
 
 Cases illustrating the author's plan of treatment, and showing the in- 
 fluence of remedies, and the share which each remedj' takes in 
 effecting a cure .......... 223
 
 CONTENTS. XIX 
 
 CHAPTER IX. 
 
 ox THE STATISTICS OV HEAUT DISEASE IN' CONNECTION WITH RHEUMATISM. 
 
 PA<iK 
 
 Statistical records of rheunmtic heart affections, most important . . 23;) 
 Dlfficnltics wliich present themselves in instituting a comparison between 
 
 the reports of various observers ....... 235 
 
 Cases from which the authors's inferences are drawn .... 237 
 
 Table exhiliiting the proportion of cases in which some form of heart 
 
 affection occurred I 
 
 " the proportion of cases in wliiuh recent heart affec- 
 
 tion occurred ...... 
 
 " the proportion of ca.ses in which old-standing heart 
 
 disease existed ...... 
 
 Inferences as to the proportion Avhich ohl-standing heart disease bear.'^ to 
 acate and subacute rheumatism viewed conjointly, and to acute and 
 subacute rheumatism taken separately . . . . .240 
 
 Proportion of diJses of acute rheumatism in which some form of recent 
 heart affection occurs, as shown by the experience of various 
 observers ........... 240 
 
 Facts tending to corroborate these results ...... 240 
 
 Proportion of cases in which heart affection occurs under author's 
 
 method of treatment ......... 240 
 
 Observations in reference to the frefiiiency of pericarditis in acute ilieu- 
 
 matism . . . . . .2 12 
 
 •' freciuency of recent endocardial affec- 
 
 tion in acute rheumatism . . . 24-'. 
 " relative frequency of recent exocardial 
 
 and endocardial affection in acute 
 rheumatism ..... 244 
 
 Tables exhibiting the result of these observations ..... 24 I 
 
 Author's explanation of the great excess in the frequency of endocardial 
 
 affection displayed in these tables ....... 24ri 
 
 Influence of age in determining the access of cardiac affection . . 24 7 
 
 " of sex 248 
 
 Connection which e.tists between the form which the articular symptoms 
 
 assume and the liability to heart affection ..... 240 
 
 Period of the attack at which heart affection most commonly arises . 2.">(» 
 Heart affections observed less frequently in primary than in subsequent 
 
 attacks of acute rheumatism ........ 252 
 
 Pericarditis and true inflammation of the endocardium more frequent in 
 
 primary than in subsequent attacks of acute rheumatism . . 2:>:i 
 T.vKLE I. — Exhibitingthenumberof cases of acute and subacute rheuma- 
 tism which were complicated by disease of the heart; the 
 age and sex of the patients in whom it occurred ; tlic form 
 which it assumed ; and the proportion in which each form 
 occurred anion"' the two sexes ...... 2o.'5
 
 XX CONTENTS. 
 
 TAUB 
 
 Table II. — Exhibiting tliu same facts in regard to acute rheumatism, 
 
 viewed separately ........ '2r)4 
 
 " III. — E.xhibiting the same facts in regard to subacute rhenma- 
 
 tisni, viewed separately ....... 255 
 
 CHAPTER X. 
 
 ox AFFECTIONS OF THE BlUl.S', IXFLAMM ATIO.N OF TJIE LUNGS AND PLECR/K, AND 
 DISORr.AXIZATION OF THE JOINTS, A.S C0.MPLICATIUN3 AND CONSEQUENCES Or 
 ACUTE KHEU.MAT1SM. 
 
 Delirium occurring in the course of acute rheumatism, formerly referred 
 to inflammation of the brain : sometimes, though rarely, referable to 
 that cause 257 
 
 More generally connected with acute inflannnation of some internal 
 organ, and occurs sometimes Mithout any concurrent internal in- 
 flammation ........ ^ . . 258 
 
 True interpretation of the head symptoms which occur in acute rheu- 
 matism ............ 258 
 
 Convulsions and spasmodic actions indicative of spinal irritation, arc due 
 to precisely the same circumstances as the delirium and other symp- 
 toms referable to the brain ........ 204 
 
 Class of cases in which cerebro-S])inal symptoms are most apt to arise. 
 
 Case in illustration 2G5 
 
 Cerebro-spinal symptoms always indicative of extreme danger, but not 
 
 necessarily of a fatal issue ........ 265 
 
 Cases in illustration of the above-stated facts : 
 
 1st. Cases in which there was true inflammation of the brain . 271 
 
 2d. Cases in which there was acute inflammation of some internal 
 
 organ, but no inflammation of the brain .... 272 
 3d. Cases in which there was neither inflammation of the brain, nor 
 
 of any other internal organ ....... 273 
 
 Cases illustrative of the severity which spinal symptoms may assume in 
 
 connection with acute rheumatism ....... 277 
 
 Cases showing that recovery may take place, even when the cerebro- 
 spinal symptoms are most alarming ...... 278 
 
 Practical suggestions as to the treatment of cases in which cerebro- 
 spinal symptoms present themselves ...... 27y 
 
 Inflammation of the lungs or pleuric, a most formidable complication of 
 
 acute rheumatism. .......... 282 
 
 Frequency of its occurrence ......... 28.3 
 
 Result of Dr. Latham's experience. Author's e.xpcrience at St. George's 
 
 Hospital 283 
 
 Circumstances to be borne in mind, in the treatment of rheumatic in- 
 flammation of the lungs 284
 
 CONTENTS. XXI 
 
 TAGE 
 
 Cases in illustration of the severity of the symptoms, and of the treatment 
 
 to be adopted .......... 280 
 
 Record of certain fatal cases, with the j!)06-i-?rtor<em appearances . . 288 
 
 Disorganization of the joints is anollier formidable complication of acute 
 
 rheumatism ........ . . 290 
 
 Liability to its occurrence usually varies in an inverse proportion to the 
 
 number of joints affected ........ 201 
 
 Cases in illustration of the treatment to be adopted .... 291 
 
 Record of post-mortem appearances in certain cases .... 292 
 
 Summary of treatment to be employed ..... . 294 
 
 CHAPTER XI. 
 
 ON UHEL-M.VTIC GOUT. 
 
 Rheumatic gout jjartakes in part of the nature of rheumatism, in part of 
 
 that of gout, but is not identical with either. Has a special pathology 295 
 
 In its acute form is liable to be mistaken for acute rheumatism . . 290 
 
 Closely connected with malassimilation ...... 296 
 
 Age at which, and sex in which, it most commonly occurs . . . 297 
 
 Symptoms w-hich mark its acute attack ...... 297 
 
 Complications which attend it ....... . 299 
 
 Question, whether an attack which commences as acute rheumatism may 
 
 not change its type, and terminate as rheumatic gout . . . 290 
 
 Diagnosis of the disease in a chronic form ...... 300 
 
 Distortions which it occasions ........ 301 
 
 Nature of the changes induced in the joints ...... 300 
 
 Evidence of the distinctive character of the disorder, derived from the 
 
 condition of the joints after death ....... 304 
 
 Mode of determining the nature of the disease when deep-seated joints 
 
 are affected ........... 30G 
 
 Treatment of the acute form of the disease, occurring in previously 
 
 healthy persons. Remedies which prove most useful . . . 307 
 Means to be employed when the disease remains fixed in a particular point 310 
 Benefit to be derived from baths of various descriptions . . .311 
 Treatment to be adopted when the patient is cachectic, and has under- 
 gone repeated attacks of the disease ...... 312 
 
 Value of the Fraxinus excelsior, the arnica raontana, the biniodide of 
 
 mercury and arsenic in certain cases 318 
 
 External applications which prove most beneficial. The frequent neces- 
 sity for their use. To be varied according to the nature of the ' 
 symptoms .... ....... 324 
 
 Plan of treatment to be adopted when contraction of the joints has taken 
 
 place . . . . . . . . . . . .327 
 
 General rules in regard to diet, exercise, and clothing .... 329
 
 xxii CONTENTS. 
 
 PAHE 
 
 Henelicial inlluunce of change of scene and air, and curative ett'ects of 
 
 various thermal springs. Different baths useful in different cases . o.'!2 
 Cause of the. extreme intractability of certain cases .... .334 
 Necessity for caution in -watching for the supervention of head-symptoms, 
 
 and for taking active and immediate measures for their subjugation 336 
 Pleurisy in connection with rheumatic gout. When most dangerous . ;'37 
 Deafness as a complication of rheumatic gout. Its cause and mode of 
 
 treatment ........... 337 
 
 Inllammation of the eye. Frequency of its occurrence. I'art uf the 
 
 eye affected. Treatment to be adopted ...... 338 
 
 Cases illustrative of the treatment of rheumatic gout .... 340 
 
 Table exhibiting the temperature and constituents of various thermal 
 
 springs ............ 347 
 
 CHAI'TKIl XII. 
 
 CUUO.MC RHKfMATISM. 
 
 Acute and chronic rheumatism identical in their .source and nature. The 
 acute may lapse into the chronic form, and the chronc may light up 
 into an active state . . . . . . .351 
 
 Parts principally affected in chronic rheumatism ..... 352 
 
 Muscular rheumatism, ciiaracter of the pain 3.52 
 
 Lumbago. Symptoms. If neglected, apt to be very obstinate . . 353 
 
 Stiff or wry neck. Character of the pain 354 
 
 Intercostal rheumatism. Pain increased by inspiration. How to be dis- 
 tinguished from pleurisy 354 
 
 Muscular rheumatism often leads to wasting of the limb . . . 355 
 Symptoms -which characterize affection of llie ligaments, and the struc- 
 tures surrounding the joints 355 
 
 Symptoms which accompany affection of the bursa' and synovial mem- 
 
 'jrane 35G 
 
 Gonorrhocal rheumatism. Its nature and symptoms. Eyes often impli- 
 cated. Apt to be extremely obstinate 356 
 
 Periosteal rheumatism. Its symptoms 358 
 
 Pain of nodes on the cranium liable to be mistaken for ordinary hcad- 
 
 •■iche 3J8 
 
 Class of patients among whom periosteal rheumatism is most common 359 
 
 Pains of chronic rheumatism most severe at night . . . . 35!;» 
 
 " " sometimes aggravated by heat . . 300 
 
 Points to be remembered in the treatment of chronic rheumatism . . 360 
 Valuable properties of the ammoniated tincture of guaiacum. How to 
 
 be used ••........ 361 
 
 The Mistura Guaiaci and jiowdcred guaiacum. When serviceable . :!62 
 
 Tcrcbintbinate medicines often bcuclicial 36.'!
 
 CONTEXTS. 
 
 xxin 
 
 Sassafras in man)- cases a useful remedy ..... 
 
 Diluents extremely serviceable in aid of other remedies 
 
 Sulphur often beneficial . . . . . . . ■ . 
 
 Colchicum, when useful . . . . . . . . 
 
 loidide of potassium. Most efficient in periosteal rheumatism 
 Mezereon, when and how to be employed ..... 
 
 Cod-liver Oil. When and how far beneficial ..... 
 
 Hydrochlorate of Ammonia of great value in muscular rheumatism 
 Arsenic extremely useful when tlie skin is harsh, and tliere is a want of 
 
 tone and nervous energy ........ 
 
 Mercury, when to be employed, and in what form .... 
 
 Value of opiates . . ... 
 
 Other sedatives — belladonna, stramonium, conium, hyoscyamus. and the 
 
 Cannabis Indica — often serviceable ...... 
 
 Aconite a very valuable remedy. Class of cases in which it is mosi 
 
 efficacious 
 
 Purgatives. When most useful ....... 
 
 Local applications of great efficacy in lumbago and stiff neck 
 Sir Anthony Carlisle's hot iron. Mode of applying it . 
 Effects of a frigorific mixture as applied by Dr. J. Arnctt 
 Oil of turpentine very useful in lumbago ..... 
 
 Benefit to be derived from baths ....... 
 
 Blisters, when to be made use of ...... . 
 
 Liniments and fomentations useful, not only in muscular rheumatism 
 
 but also when the joints are affected ..... 
 Aconitine and veratria ointments. Their singular eflicacy in certain 
 
 cases ........... 
 
 An alcoholic solution of Aconitine to be employed, when the ointment is 
 
 inapplicable .......... 
 
 Precautions to be taken against cold, when the patient leaves the house 
 Electricity, galvanism, and acupuncturation. Their respective merits as 
 
 curative agents .......... 
 
 Good results occasion.ally accrue from a brief residence in a warm 
 
 climate ........... 
 
 PAGE 
 
 363 
 364 
 365 
 
 365 
 365 
 366 
 366 
 367 
 
 367 
 
 36S 
 371) 
 
 370 
 
 371 
 373 
 374 
 375 
 376 
 378 
 378 
 379 
 
 380 
 
 380 
 
 381 
 3«1 
 
 382 
 
 CHAPTER XIIL 
 
 ON S('I.\TI(:A, and OTHKR forms of NEUIIALGIC RHEUMATISM. 
 
 Rheumatism which attacks the nerves, easily distinguished from other 
 
 forms of rheumatism ......... 384 
 
 Position and character of the pain in sciatica ..... 384 
 
 Age at which, and sex in which, it most frequently occurs . . . 385 
 
 Apt to prove intractable, and the reason why ..... 386
 
 xxiv CONTENTS. 
 
 PAOB 
 
 Points to be ascertained before deciding upon a plan of treatment . . 387 
 Diseases which have been mistalceu for sciatica, and bow they may be 
 
 distinguished 387 
 
 Nature of the treatment dependent on a due recognition of the primary 
 cause of the disease, as also of the stage at which the complaint 
 has arrived ........... 388 
 
 Diagnosis of effusion into the sheath of the nerve 390 
 
 Remedies which prove most useful in checking effusion, and in pro- 
 moting its absorption ......... 393 
 
 Acupuncturation, when and how far serviceable ..... 394 
 
 Effusion into the sheath of the nerve by no means a common occur- 
 rence 395 
 
 Opium, belladonna, stramonium, hyoscyamus, conium, and the Cannabis 
 InJica — their value as sedatives. Their mode of action. Points to 
 be borne in mind before deciding on their administration . . 395 
 Efficacy of this class of remedies when applied externally . . . 307 
 Extraordinary effect when injected into the cellular tissue . . . 398 
 Digitalis, aconite, and veratria: their antineuralgic properties, the mode 
 in which they should be employed, and the class of cases in which 
 their curative influence is displayed ...... 401 
 
 Blisters, moxas, and the actual cautery : their respective merits . . 404 
 Galvanism and electricity, cases in which they prove most serviceable . 406 
 
 Congelation, its effects . 406 
 
 Firm and continued pressure, good results attributed to it . . . 408 
 Extraordinary efficacy of sulphur applied externally .... 409 
 
 Stimulating liniments and other external applications have been made 
 
 use of. Which most serviceable ....... 409 
 
 Influence of baths, and the natural mineral waters, as curative agents . 411 
 Local baths of various descriptions of the greatest service . . . 412 
 Quinia, iron, zinc, arsenic, and other tonics: their mode of action, and 
 
 the circumstances under which they prove beneficial . . . 413 
 Frequent connection of sciatica, and other forms of neuralgic rheuma- 
 tism, with the presence of oxaluria. Treatment required in such 
 cases. Its modus operandi ........ 413 
 
 Points to bo remembered in the diagnosis of rheumatic affection of other 
 
 nerves . . . . . . . . . . . .415 
 
 In these instances, as in the case of sciatica, a correct diagnosis is essen- 
 tial to the adoption of eflicient remedies . . . . .415 
 
 External applications which have been found serviceable ^ . . .410 
 Cases illustrative of the treatment of sciatica and facial neuralgia . 41G
 
 RHEUMATISM, RHEUMATIC GOUT 
 
 SCIATICA. 
 
 CHAPTER I. 
 
 INTRODUCTION. 
 
 " Quamvis enim cedere auctoritate debeani, rectius tamen arbitror, in 
 tanta re, ratione quam auctoritate superari." — Pliny, Lib. i, Ep. 20. 
 
 Few diseases are more deserving of attention than that com- 
 oaon, painful, and obstinate malady which has been recognized 
 under the title of Rheumatism. Whether vicAved in relation to 
 the number of its victims, the amount of present suffering it 
 inflicts, or the terrible disease of the Heart which it entails, it 
 ranks among the most formidable of human ailments. Its im- 
 portance, however, in the estimation of the physiologist is de- 
 rived, not only from its prevalence and severity, but from the 
 mystery in which it has ever been involved. Obscure in its 
 origin, and in its subsequent course uncertain and variable, its 
 source has hitherto remained undiscovered, its phenomena un- 
 explained, its treatment unsatisfactory ; and, by common con- 
 sent, it is ascribed to a cause which affords not the slightest 
 clew to its nature, nor the least explanation of its varied phe- 
 nomena. 
 
 Many persons consider exposure to cold sufficient to induce 
 an immediate attack ; and though rheumatism not unfrequently 
 occurs without the slightest exposure, though even when ex-
 
 26 INTRODUCTION. 
 
 posure lias taken place, fresh joints are attacked long after all 
 exposure has ceased ; nay, more, though the ascertained local 
 and general effects of cold differ altogether from the symptoms 
 of rheumatism, yet some, even among the profession, have 
 been found to adopt this prevalent notion, without an attempt 
 to show that cold either does or can produce the effects assigned 
 to it. 
 
 Others have endeavored to point out the precise nature of 
 the influence exerted, and have suggested that cold, by sus- 
 pending cutaneous secretion, and so giving rise to the retention 
 of effete matters in the blood, is explanatory of the varied phe- 
 nomena of the disease. But rheumatism may, and does some- 
 times occur under circumstances which entirely preclude the 
 agency of cold ; — it is not by any means of common occurrence, 
 even when the skin's function is suspended by disease ; and 
 when once it has arisen, it sometimes continues with great 
 severity for months after the action of the skin has been re- 
 established, and profuse and constant perspiration has been 
 set up. 
 
 By others, a temporary exposure to cold has been justly 
 deemed insufficient to account for symptoms so severe and 
 erratic in their nature, so variable in their mode of onset, and, 
 in many cases, so extremely obstinate in their continuance. 
 Accordingly, of late years, a theory has been broached more 
 consistent with the train of physical events, and rheumatism 
 has been referred to the irritation of a morbid matter in the 
 blood, which though possibly derived, in part, from the stop- 
 page and consequent retention of the perspiration, through the 
 influence of cold, is, to a far greater extent, generated in the 
 system, as a product of impaired or perverted assimilation — of 
 vicious matamorphic action. 
 
 This doctrine is as yet imperfectly understood, and even by 
 its warmest advocates has been hardly carried to its legitimate 
 conclusion. It may be well, therefore, to explain the grounds 
 on which its acceptance rests, to point out the universality of 
 its application, and to show how important is its practical 
 bearing. a
 
 INTRODUCTION. 27 
 
 First, however, it will be necessary to advert to the local 
 and general elFects of exposure to cold, as actually proved by 
 experience. 
 
 When any part of the body is subjected to a low temperature, 
 or to the combined influence of cold and moisture, the first 
 symptom of such exposure is a sensation of cold in the part 
 exposed, accompanied by a pallor or blueness of the skin. If 
 the exposure be of short duration, and the degree of cold mod- 
 erate, the circulation is soon re-established after removal from 
 the cold, and no ill results ensue. 
 
 When the degree of cold is greater, or the exposure of longer 
 duration, a shrunken state of the skin supervenes, the circu- 
 lation in the part is partially and sometimes almost entirely 
 arrested, and when warmth is again applied, gangrene may 
 result, if care be not taken to prevent reaction taking place 
 too rapidly. If proper caution is observed, nothing unusual 
 is remarked in the part beyond a temporary glow or increased 
 heat, which gradually subsides altogether. 
 
 If the intensity of the cold be still greater, or exposure even 
 to a moderate degree of cold be of longer duration, the parts 
 exposed Avill probably be frost-bitten and become gangrenous 
 and die. In every instance the local effects, though varying 
 somewhat in different persons, are proportioned, cseteris paribus, 
 to the intensity of the cold and the duration of the exposure, 
 and are manifested only in the parts exposed. 
 
 Y[ie general effects of exposure to cold are equally well known, 
 and are also strongly marked. Up to a certain point, which 
 varies in different individuals according to their condition and 
 the activity of the circulation, cold evidently acts as a decided 
 stimulus. It produces muscular contraction, and imparts vigor 
 to the system. But intense cold, or long-continued exposure 
 even to a moderaiie degree of cold, has a directly opposite 
 effect. It gives rise to chilliness, or even shivering, with mus- 
 cular and nervous exhaustion, a diminution in the force of the 
 heart's action, and general depression of all the natural func- 
 tions. This depressing influence may proceed to such an extent 
 as to produce a species of stupor, an^almost irresistible desire
 
 28 INTRODUCTION. 
 
 to sleep, with excessive feebleness of the heart's action, and 
 death as its natural result. 
 
 It will be observed that the phenomena primarily produced 
 by cold are totally unlike the symptoms of rheumatism.^ No 
 wandering pains ; no redness or swelling of the joints ; no symp- 
 toms, indeed, of any moment present themselves unless the cold 
 be intense, and even then they bear no resemblance to the ' 
 symptoms of rheumatism. Nay, more than this: the experi- 
 ence of travelers has proved beyond all question, that in 
 healthy persons, the most extreme and rapid variations of tem- 
 perature are insufficient to excite the disease.^ 
 
 Some persons, however, maintain that cold, though of itself 
 inert, becomes a poAverful agent in the production of rheumatism 
 when acting in conjunction with damp and moisture. Doubt- 
 
 1 I employ the word primarily with the view, firstly, of pointing out that 
 rheumatism does not occur as an immediate effect of mere abstraction of heat ; 
 and, secondly, of guarding against the supposition that cold is never concerned 
 in its production. It will be seen, in the latter part of this chapter, that cold 
 does sometimes prove the efficient cause of the disease, by exercising a depress- 
 ing influence, interfering with the business of nutrition, and so, through per- 
 verted assimilation, giving rise to the formation of the materies morbi. But 
 I wish it to be distinctly understood, that mere abstraction of heat will not 
 produce rheumatism, except in the indirect manner just alluded to, and that 
 the disease, therefore, cannot be attributed strictly to cold. The only true or 
 essential cause of the disease is a poison in the blood, the formation of which 
 may be occasioned by many accidental causes of perverted nutrition, of which 
 exposure to cold is one. 
 
 -' Captain Parry, in his account of " A Voyage for the Discovery of a North- 
 west Passage," observes, (p. 134,) " We were constantly in the habit for some 
 mouths of undergoing a change of from 80° to 100°, and in several instances 
 of 120° of temi)erature in less than a minute ; and what is most extraordinaryi 
 not a single infiammatory complaint, beyond a slight cold, which was cured by 
 common care in a day or two, occurred during this particular period." Through- 
 out the expedition, the occurrence of rheumatism, or, indeed, even of rheumatic 
 pains, was exceedingly rare. 
 
 Again, Colonel Sir J. Mitchell, in his " Journal of an Expedition into the 
 Interior of Tropical Australia," reports that " they were subjected almost daily 
 to variations of temperature of nearly 50°," and yet he makes no mention of 
 the occurrence of rheumatism. 
 
 And again, it appears from the statistical reports of cases which have occurred 
 among our troops stationed in different parts of the world, that out of every 
 1,000 patients admitted into the military hospitals, there are fifty-seven cases 
 of rheumatism at the Cape of Good Hope, the land of heaths and geraniums, 
 and thirty only in the cold and variable climate of Nova Scotia and New 
 Brunswick.
 
 INTRODUCTION. 29 
 
 less, under such circumstances, it proves an active predisposing 
 cause of this, in common with many other disorders; and it 
 may also become an exciting cause when a predisposition already 
 exists. But the significant fact, that numberless persons are 
 constantly exposed to the combined influence of cold and moist- 
 ure, and that nevertheless no instance is on record in which 
 rheumatism has occurred simultaneously in any large number 
 of persons, is sufficient to show that the influence alluded to 
 cannot be the proximate or essential cause of the disease. 
 Amidst all the horrors of the Russian campaign, with sleet 
 falling, and men dying on all sides from the effects of cold and 
 wet, it was hardly more prevalent than at any other time ;* and 
 the same observation has been made, when soldiers, heated by 
 their march and drenched to the skin, have had to repose on 
 the cold wet ground.^ 
 
 Indeed, it needs little observation to prove tliat cold and 
 atmospheric vicissitudes are not essential to the production of 
 rheumatism. Persons in private life are frequently seized with 
 active symptoms of the disease without having been subjected 
 to the slightest exposure ; and in hospital practice, patients who 
 have been admitted for some other complaint, and have been 
 confined to bed for weeks in a ward heated up to 65° Fahren- 
 heit, are sometimes attacked by it in a most violent manner. 
 In such instances the symptoms are just as severe, and continue 
 just as obstinately as in cases where there has been the greatest 
 exposure.^ 
 
 1 During the three or four exceedingly cold days which immediately pre- 
 ceded the battle of Eylau, the mercury had fallen to 10, 11, 12, 13, 14, and 15 
 degrees below zero, of Reaumur's thermometer, (or, in other words, to below 
 zero of Fahrenheit;) and during these days, and during a great portion of the 
 nights of the 5th, 6th, 7th, 8th, and 'Jth of February, " the soldiers had been 
 exposed to the snow and frost," yet " no ssldier presented himself at the am- 
 bulance," and "it was not until the night of the 10th, when the temperature 
 had risen about 18 or 20 degrees, that they felt the first effects of cold." They 
 then began to suffer, not from rheumatism, but from " gangrene of the extremi- 
 ties, one of the common and true effects of cold." — (Baron Larrey's " Memoires 
 de Chirurgie Jlilitaire," vol. iii.) 
 
 '^ Pringle's "Observations on Diseases of the Army." 
 
 3 Numberless cases of this sort might be cited, but one which T take at ran- 
 dom from my note-book will suffice for an illustration of the subject. William
 
 30 INTRODUCTION. 
 
 But more than this: it frequently happens that some ten 
 (lays after the commencement of an attack, the knee, or some 
 part which had previously escaped, hecomes hot and red, and 
 swollen. Whatever the cause of the first articular inflammation, 
 the fresh inflammation cannot reasonably be attributed to the 
 efi'ect of cold, inasmuch as from the patient being confined to 
 bed, the joints are necessarily protected from its influence. In 
 order, therefore, to account for this singular phenomenon, a 
 vague and untenable hypothesis has been resorted to; and it 
 has been suggested, that the fresh inflammation set up is due 
 to a transference of inflammatory action from another part of 
 the body. In some instances such may be the case, but obser- 
 vation has proved that it is usually a mere extension of the 
 disease, occurring where no subsidence of inflammation has 
 taken place. 
 
 Sometimes when the complaint has nearly run its course, and 
 the pain and inflammation have in great measure subsided, the 
 symptoms recommence in all their severity without fresh expo- 
 sure, and without any obvious exciting cause. Even had the 
 first attack arisen from cold, the recurrence of the disease with- 
 out fresh exposure proves it totally independent of any such 
 agency. 
 
 The same fact is fully and unequivocally attested by the 
 history and entire progress of the complaint. The articular 
 symptoms of rheumatism are extremely migratory ; they do not 
 cease on the re-establishment of perspiration, and they are 
 sometimes preceded, and after a time very frequently accom- 
 
 Edmonds, aet 34, who was admitted into St. George's Hospital on the 30th of 
 April, 1840, under the care of Mr Keate, was contined to his bed by severe 
 ulceration of his leg. He was much out of health, but presented no symptoms 
 of rheumatism until the 2oth of May, when, after lying in bed for a period of 
 nearly four weeks, he was seized with wandering rheumatic pains. These 
 gradually increased in severity, and on the 1st of June his right hip became 
 exquisitely painful, and both his hands and wri.^ts red, swollen, and inflamed) 
 In short, an attack of acute rheumatism commenced, and, in spite of treatment, 
 ran its usual course. Sueh instances have not escaped the notice of the ob- 
 servant Mons. Chomel ; and, accordingly, after quoting several in point, he has 
 expressed it as his opinion, (''Lemons de Clinique Medicale," torn, ii, p. 153,) 
 that " the impression of cold is not a necessary precursor of acute rheumatism."
 
 INTRODUCTION. 31 
 
 panied by inflammation of tlie membranous envelopes of the 
 heart. 
 
 If they were due to cokl, locally applied, they should surely 
 be stationary, as are all local symptoms known to depend on 
 local causes: if due to the repression of the perspiration by 
 cold they should certainly cease, or be relieved in some measure 
 by the re-establishment of the skin's action ; the more so, as in 
 rheumatism the perspiration is excessive, and in its duration 
 most remarkable : and if referable to cold the heart should 
 surely escape unscathed, protected as it is on all sides from the 
 influence of cold. On this point experience speaks decisively, 
 and shows that for some time the heart is not afi'ected even 
 under the influence of intense cold; and that when after pro- 
 longed exposure it is aff"ected even unto death, not the slightest 
 inflammatory action is produced, but its impulse becomes feeble, 
 after a time irregular, and ultimately ceases altogether. On 
 what, then, do the symptoms of rheumatism depend? 
 
 If certain substances are introduced into the circulation, 
 fever is set up, rigors often occur, and inflammatory symptoms 
 very shortly supervene in various parts of the body; symptoms 
 which vary in intensity and locality, according to the amount 
 and character of the poison. And if the blood be altered in 
 character it is practically the same, whether it contain matters 
 foreign to the system and altogether morbid in kind, or whether 
 it contain an excess only of some material, a certain amount of 
 •which is compatible with health. In either case it is unhealthy 
 and poisonous in its nature ; in either case it contains a " materies 
 morbi," which may not only produce fever, or the symptoms of 
 general derangement, but, if irritating in its nature, may give 
 rise to local inflammatory symptoms. Assuming, then, that 
 an abnormal condition of the blood may account for the pain, 
 inflammation, and the curious train of symptoms which consti- 
 tute an attack of acute rheumatism, I shall endeavor to show 
 that such a condition does actually exist in this disease, and 
 that it is mostly, if not wholly, referable to constitutional causes. 
 
 Many of the most remarkable features of rheumatism are 
 quite characteristic of a disease dependent on a vitiated con-
 
 32 INTRODUCTION. 
 
 dition of the circulating fluid. Its attacks are ushered in by 
 premonitory fever ; its local symptoms are erratic, and yet 
 remarkably symmetrical in their arrangement : the heart, the 
 lungs, and other internal organs are prone to be affected ; and 
 when metastasis occurs, the constitutional symptoms are such 
 as are met with under similar circumstances in diseases known 
 to be connected with a vitiated blood. 
 
 In some cases, the fever is at first so slight as hardly to 
 attract attention ; and then, as in instances occasionally met 
 with among the eruptive fevers, the appearance of the local 
 symptoms affords the first noticed indication of existing dis- 
 ease. But more commonly the patient has been " out of 
 sorts," for some time prior to the full development of the 
 attack ; he has probably felt languid, chilly, and uncomfort- 
 able ; the appetite has been capricious ; he has had a sour or 
 bitter taste in his mouth, and has experienced dull, aching 
 pains in the limbs ; — symptoms which indicate constitutional 
 derangement, and together mark the onset of fever. And it 
 will be observed that, in many important respects, this rheu- 
 matic fever differs from that which results from local mischief. 
 The fever which accompanies local affections is invariably 
 developed after the commencement of local mischief, is com- 
 mensurate with its intensity, and decreases or increases in 
 exact proportion to the extent and intensity of the local mis- 
 chief; whereas in i-heumatism, as in other diseases known to 
 be dependent on a poisoned blood, it generally precedes, for a 
 considerable time, the full development of the local symptoms, 
 not unfrequently decreases directly local inflammation is set 
 up,' and is invariably aggravated by its sudden or premature 
 subsidence. 
 
 So also in regard to the erratic natm-e of the articular 
 inflammation. When inflammatory action is excited by a 
 truly local cause, as, for instance, by a blow, nobody ever 
 imagines that it can possibly subside in the spot first affected, 
 
 ' " Febri3 nutem scnsem evanescit, manente dolore, quin et nonnunquam 
 inmanius sa^viente, materia scilicet febriii in artus translata." (Sydenhami 
 Opera, sect, vi, cap. v.)
 
 INTRODUCTION. 33 
 
 and reappear in some distant part of the body. On the con- 
 trary, it is an admitted fact that, when any mischief is really 
 local, the inflammation is also lo(!al and stationary. On the 
 other hand, whenever the blood is poisoned, as when pus, for 
 instance, has been taken into the circulation, we are never 
 surprised at the occurrence of symptoms in any part, however 
 distant from the original seat of mischief, inasmuch as the 
 poison circulates with the blood to every tissue of the body, 
 and may irritate and ultimately excite inflammation in several 
 parts successively. Thus the joints, the heart, the lungs, and 
 the nervous centers, may be affected simultaneously or in suc- 
 cession, while the functions of the skin, the liver, and the 
 kidneys may also be more or less interfered with. Such, also, 
 is the case in regard to rheumatism. 
 
 On the same ground, the symmetry of the local symptoms 
 of the disease affords additional evidence of the poisoned con- 
 dition of the circulating fluid. For if the blood itself be at 
 fault, it is but consistent with reason to suppose that, perme- 
 ating as it does every tissue of the body, it should ultimately 
 give rise to similar changes in parts corresponding in function 
 and organization, whereas, under any other supposition, the 
 proneness of the disease to affect similar parts on either side 
 of the body is utterly inexplicable. The peculiarity in ques- 
 tion has been shown by Dr. W. Budd' to obtain in all disorders 
 connected with a vitiated condition of the circulation, and why 
 take exception to rheumatism ; why exclude a disease pre- 
 senting such curious illustrations of the fact ? 
 
 Again, that inflammation of the heart is liable to arise, and 
 forms one of the most frequent as it is one of the most formi- 
 dable complications of rheumatism, is a fact most painfully 
 verified by experience, and it is equally certain that it some- 
 times occurs prior to the setting up of any articular or other 
 external symptom of the disease.^ In casea where it is pre- 
 ceded by pain, redness, and swelling of the joints, it has been 
 ascribed to a transference of morbid action consequent on the 
 
 ' " Medico-Chir. Trans.," vol. xxv. 
 2 See Cap. VI of this Treatise.
 
 34 INTRODUCTION. 
 
 subsidence of articular inflammation. The advocates of this 
 doctrine have never attempted to explain in what way such 
 translation takes place, and have failed in showing that it 
 does occur in any disorder known to be truly local, yet they 
 have not hesitated to urge this view in explanation of the 
 phenomenon in question. But even if admitted to its fullest 
 extent, it utterly fails in elucidating the symptoms. For in 
 the majority of instances where pericarditis or endocarditis is 
 met with, there is not the slightest, even temporary, subsidence 
 of the external or articular inflammation ; and since inflam- 
 matory action about the heart is occasionally the earliest, and 
 for some time the onit/ local symptom of rheumatism, metas- 
 tasis, however vaguely understood and applied, must obviously 
 fail in clearing up the mystery. Indeed the only explanation 
 appears to be that the heart is aff"ected through the agency of 
 the blood, which from some cause has become unhealthy and 
 irritating in its character.^ 
 
 On the other hand, the symptoms usually observed when 
 metastasis does in reality take place, when the external inflam- 
 mation suddenly subsides, and cardiac inflammation simulta- 
 neously or shortly afterward commences, afi"ord most striking 
 confirmation of this view, for they correspond precisely with 
 those observed under similar circumstances in cases where the 
 blood is known to be aff"ected. Rigors almost invariably occur, 
 followed by increase in the febrile symptoms; there is. gen- 
 erally much anxiety of countenance, and evidence throughout 
 of constitutional irritation ; the breathing is hurried, the heart's 
 action accelerated and sometimes irregular, and before the 
 symptoms are again locally fixed, it not unfrequently becomes 
 intermittent. In the mean time pains of a spasmodic character 
 occur in various parts of the body ; hiccough ensues, or vomiting, 
 or perhaps diarrhoea supervenes, which, though usually but 
 little under the control of medicine, subsides together with 
 
 1 Mons. Chomel, among others, has recorded a series of most interesting 
 observations, which tend to show, that the internal inflammations in rheuma- 
 tism, like those of smallpox, typhus, scarlatina, &c., are referable to an alter- 
 ation of the animal fluids, more especially the blood. (-'Legons de Cliaique 
 Medicale," 1834, pp. 529-539.)
 
 INTRODUCTION. 3& 
 
 the other phenomena on the re-establishment of local 
 symptoms.^ 
 
 The fact is, the doctrine of a poisoned blood in rheumatism, 
 though seldom fully recognized in theory, is tacitly allowed full 
 weight in determining some points in practice. When a person 
 is suffering from the irritation of a diseased joint, the result of 
 local injury, amputation by removing the part affected gets rid 
 of the disease, and the accompanying fever ; and if rheumatic 
 inflammation were in like manner a purely local affection, the 
 knife would in that case also effect a radical or permanent cure. 
 But no one would propose the adoption of such a remedy in 
 the case of an inflamed rheumatic joint. The fruitlessness of 
 such an attempt to get rid of the disease is at once acknowl- 
 edged and acted on : the blood itself being the source of irri- 
 tation, the mere removal of one of the local effects of that 
 irritation would obviously be ineffectual in eradicating the com- 
 plaint ; the inflamed part might be removed by the scalpel, but 
 there would be nothing in its removal to prevent the immediate 
 occurrence of inflammation in any other part of the body.^ 
 
 If further proof were required, I might refer to the analogy 
 between rheumatism and gout. 
 
 So curiously do these two disorders coincide, so imperceptible 
 in certain cases is the transition from the one to the other, 
 that there is no little difficulty in distinguishing between them. 
 
 1 Dr. Holland remarks, ("Medical Notes and Reflections/' cap. "Metastasis,") 
 " The high state of fever, notable disturbance of the heart, and of other func- 
 tional derangements which constantly occur during the translation of disease, 
 and which subside in great measure when the symptoms are again locally 
 fixed, is a powerful argument in favor of a morbid matter in the blood itself.'' 
 
 In rheumatism, such phenomena are somewhat rare, but I have seen three 
 instances of their occurrence. One was the case of a boy, set. 16, under my 
 own care at St. George's Hospital ; another, that of a man in King's Ward, 
 under the care of my colleague Dr. Wilson ; and the other that of a lad admit- 
 ted into Fuller's Ward, under the care of Dr. Seymour. In all these cases 
 there was extreme vascular excitement, with obstinate vomiting followed by 
 diarrhoea. 
 
 2 " The heat, redness, and swelling (of the joints) are no more the cause of 
 the constitutional disturbance in acute rheumatism, than the scarlet-rash or 
 the smallpox pustules of the fevers which bear their respective names. They 
 are but the partial expression, by impaired nutrition, of a disorder that is gen- 
 eral in the system." (Dr. Wilson on the " True Character of Acute Rheuma- 
 tism," "Lancet" for 1844, vol. ii, p. 192.)
 
 S6 INTRODUCTION. 
 
 In both, an hereditary taint may frequently be traced ; in both, 
 the fever is out of all proportion to the extent and severity of 
 the local mischief; in both, the joints are the parts principally 
 affected, and the inflammation, which is of a peculiar nature, 
 observes a remarkable symmetry in attacks ; in both, internal 
 organs are often implicated, and in both, anomalous symptoms 
 of a similar character occur v.'henever metastasis takes place. 
 And not only so : — their aflSnity becomes even more apparent 
 ■when their history is more closely and accurately examined. 
 For it is then found that while children of gouty parents are 
 peculiarly subject to attacks of rheumatism,^ the offspring of a 
 rheumatic stock no less frequently show symptoms of that 
 hybrid disorder, rheumatic gout, and in some instances of une- 
 quivocal gout. Such a striking analogy between the symptoms 
 of the two disorders is surely sufficient to warrant our assum- 
 ing a similarity of cause, and as in gout the existence of a 
 materies morbi admits of actual demonstration,^ our view is 
 confirmed, as to the existence of a poison in the blood in rheu- 
 matism. 
 
 Whence then does this poison arise ? From what source and 
 by what means does the blood become vitiated ? 
 
 There are many circumstances in the history of rheumatism 
 which point to its being of constitutional origin. 
 
 The earliest and most frequent victims of the disease, even 
 ■when considering themselves in tolerable health, are apt to 
 experience symptoms clearly denoting functional derangement. 
 Though strong, perhaps, and equal to much bodily exertion, 
 they are peculiarly sensitive to atmospheric vicissitudes, are 
 prone to perspire, and their perspiration has a sour^ disagree- 
 
 ' " Rheumatism is undoubtcdlj' nearly allied to gout, and tits of it have been 
 more common in children born of gouty parents." (Dr. Heberden's " Com- 
 mentaries," p. 399.) 
 
 '•' Dr. Garrod has demonstrated by chemical analysis the existence of uric 
 acid in the blood of gouty patients, and its absence from the blood in rheuma- 
 tism. (See " Med.-Chir. Trans.," vols, xxxi and xxxvi.) 
 
 3 A rheumatic gentleman not long since assured me, that he is unable to 
 carry a knife or other steel instrument in his pocket, in consequence of its 
 becoming rusty from the acidity of the perspiration.
 
 INTRODUCTION. 37 
 
 able odor, while their urine, though usually clear when passed, 
 not unfrequently deposits, on cooling, a red brick-dust sedi- 
 ment, a sediment of the lithates and lactates. So constantly 
 are these symptoms associated with a tendency to rheumatism, 
 that they have been recognized as indicative of a " rheumatic 
 diathesis," or, in other words, of a case of constitution pecu- 
 liarly prone to the incursion of rheumatism. And it has been 
 observed that in persons so predisposed, the heart is irritable, 
 and prone to take on inflammatory action, and that even when 
 it is not attacked by inflammation, its nutrition is apt to become 
 perverted, its valves more or less diseased, and its walls thick- 
 ened in consequence. Moreover, erratic pams ensue on the 
 slightest derangement of the general health, and are relieved 
 not by any specific treatment, but by shower-baths, or tonics, 
 or whatever tends to improve the general health. 
 
 Again, it has been remarked, that whereas certain persons 
 are subject to rheumatism, others under precisely the same cir- 
 cumstances, of the same age and sex, living in the same locality, 
 sometimes even in the very same house, exposed to the same 
 atmospheric vicissitudes, and following the same pursuits, — 
 placed, in short, in a precisely similar position with regard to 
 external influences, — remain perfectly free from the disease. 
 
 And again, that certain persons, who during the whole of 
 their previous existence have lived in perfect immunity from 
 the disease, become suddenly tormented with it on changing 
 their mode of living, or from some less obvious cause, while 
 others who had long labored under this affliction, got rid of their 
 troublesome enemy in an equally remarkable and mysterious 
 manner. 
 
 From these general facts alone it might be inferred, that the 
 materies morbi on which the symptoms of rheumatism depend, 
 is generated under certain circumstances in the system, and is 
 so generated as a result of some obscure constitutional peculi- 
 arity, some particular form of mal-assimilat'.on. 
 
 But there are other facts which tend directly to the same 
 conclusion. The disease generally makes its appearance in 
 those subject to its invasion, whenever the system is lowered or
 
 38 INTRODUCTION. 
 
 deranged. It is so frequent an attendant on disordered condi- 
 tions of the uterine system, that its intimate connection with 
 retained uterine secretions has been suggested by Dr. Todd^ 
 and other observers. M. ChomeP has been struck with the 
 frequency of its occurrence after excessive lactation, after inor- 
 dinate indulgence of the sexual desires, and during tedious 
 recoveries from fever f and all who have carefully studied the 
 disease in the vast field of observation afforded by the wards of 
 our public hospitals, must have remarked how constantly its 
 attacks have been preceded by functional derangement. 
 
 The important observation of Sir John Pringle,* that rheu- 
 matism is more prevalent at the commencement of a campaign 
 and shortly after return to garrison, than at any other period of 
 a soldier's career, comes in perfect confirmation of these inter- 
 esting gleanings from civil life. For nothing can be more in 
 accordance with experience, than that temporary derangement 
 of the system should be produced by the entire change of life 
 which a soldier undergoes when first called into the field, and 
 when again, after active service, he returns to the close con- 
 finement of the barrack. Whereas, under no other supposition 
 is it possible to account for the prevalence of the disease at 
 the very times when the soldiers are best equipped, most pro- 
 tected against atmospheric vicissitudes, and free from the 
 many privations and the exposure inseparable from active 
 service. 
 
 There are other facts of a different character which bear 
 just as strongly on the solution of this question. It has now 
 been established beyond dispute, that rheumatism, like gout, is 
 distinctly hereditary.^ And if the general law of hereditary 
 affections, as Sir Henry Holland asserts,^ be that so ably 
 
 ' On " Rheumatism," p. 149. 
 
 * " Le(;ons de Clinique Medicale," torn, ii, p. 151. 
 
 * " Enfin on le voit souvent se manifester pendant la faiblesse qui occupe 
 toujours la convalescence." (Op. cit., p. 467.) 
 
 * " Observations on Diseases of the Army," part I, cap. iii and iv ; part II, 
 cap. i ; part III, cap. iii. 
 
 * See Cap. ii, p. 32. 
 
 6 " Medical Notes and Reflections," cap. on " Hereditary Affections."
 
 INTRODUCTION. 39 
 
 developed by Dr. Prichard, viz. : that " all original connate 
 bodily peculiarities tend to become hereditary, while changes 
 in the organic structure of the individual, from external causes 
 during life, end with him, and have no influence on his pro- 
 geny," it follows that rheumatism, being an hereditary disease, 
 must be in its nature constitutional. 
 
 Perhaps the strongest proof of its constitutional origin, is to 
 be found in the variable and often long duration of the dis- 
 order. For unless it be admitted that the materies morbi may 
 be generated de novo in the system, the long continuance and 
 frequent recurrence of the articular symptoms are altogether 
 inexplicable. If the disease were dependent on a poison intro- 
 duced into the system from without, it should manifest some 
 of the peculiarities of disorders which acknowledge such an 
 origin ; it should occur more or less periodically or epidem- 
 ically : it should run a someAvhat regular and definite course, 
 and should confer upon a person who has once experienced 
 its attacks, an immunity from, or partial protection against, 
 its future invasion. But rheumatism is always met with 
 sporadically ; its career is remarkably variable and uncer- 
 tain ;^ and so far from a well-developed attack affording pre- 
 tection against its future invasion, it is generally believed that 
 a person who has once been subjected to its influence, is pecu- 
 liarly liable afterward to its invasion. And if, which is the 
 only other supposition, the disease were dependent on the 
 irritation of a matter resulting from temporary suspension of 
 the skin's function, it should subside on the re-establishment 
 of a free cutaneous action ; the more so, as in a well-developed 
 attack, the perspiration is constant and excessive. 
 
 As, then, it appears impossible to avoid the conclusion that 
 the materies morbi is generated in the system as a product of 
 mal-assimilation, or faulty metamorphic action, the next points 
 for consideration are those which serve to indicate its nature. 
 
 1 In one case, it runs a short, acute, and regular course; in another, the 
 patient experiences relapses, in each of whi'',h, the original symptoms not 
 unfrequently recur with all their former virulence ; while, in a third case, the 
 disorder lingers on for months in a semi-acute form, aggravated by irregularly 
 periodical exacerbations.
 
 40 INTRODUCTION. 
 
 A suggestion was thrown out by Dr. Prout, and has been 
 adopted and enlarged upon by Dr. Todd in his Croonian 
 Lectures, that all the phenomena of the disease are referable to 
 the presence of lactic acid, which is developed too freely in 
 the system in consequence of imperfect assimilation, and accu- 
 mulates in the blood by reason of defective cutaneous action. 
 
 "It is no wonder," says Dr. Todd, "that as lactic acid is 
 imperfectly excreted through its natural channels, in conse- 
 quence of the influence of cold in checking perspiration, and 
 is too freely developed in the alimentary canal, it should 
 accumulate in the blood and become eliminated at every point. 
 Moreover, the long continuance of the causes which produce 
 the defective cutaneous secretion and the deranged gastric 
 one, will give rise to the development of lactic acid in the 
 secondary processes of assimilation, thus infecting the blood 
 from every source, and tending to perpetuate the diathesis." 
 
 More recently this view has been somewhat modified, and 
 has received more complete and satisfactory elucidation, from 
 Dr. Headland, in his valuable treatise on the action of med- 
 icines.^ After referring to the commonly received opinion, 
 that before the starch of the food can be applied to the main- 
 tenance of the animal heat, it has to be converted into lactic 
 acid, which then combines with oxygen to form carbonic acid 
 and water, in which form it is thrown out of the system by the 
 lungs, he points out how anything which interferes with this 
 oxidation of lactic acid, must lead to its excessive accumu- 
 lation in the system. He thus suggests that simple " want of 
 vital energy or nervous force," or "a failure of some natural 
 principle which is gifted with the control and direction" of the 
 chemical changes in the blood ; or, in short, any disturbing 
 cause, of whatever nature, which may tend to prevent the nor- 
 mal series of changes from taking place, may lead to the 
 accumulation of lactic acid in the system, and so may prove 
 the accidental or exciting cause of rheumatism. And he leaves 
 it to be inferred that the disease is usually due to such causes, 
 rather than to the non-excretion of lactic acid by the skin, or 
 
 ' Headland " On the Action of Medicines," pp. 85-"j0.
 
 INTRODUCTION. 41 
 
 to its excessive formation in the primary or secondary processes 
 of assimilation. 
 
 My own opinion is strongly in favor of this view, which 
 alone of all the theories hitherto propounded, is reconcilable 
 with the admitted facts, that rheumatism may occur under a 
 great variety of circumstances, and at times when the digestive 
 organs are but little deranged ; that it may arise without any 
 exposure to cold, or arrest of the skin's function ; that it con- 
 tinues after the skin's action is re-established ; and that it may 
 be, and often is, occasioned by influences prejudicial to the 
 general health. 
 
 It is true that the poison which gives rise to rheumatism has 
 not as yet received actual demonstration, but many facts con- 
 duce to a belief in its identity with some natural excretion of 
 the skin. In advanced life, when, from want of energy in the 
 system, the skin's action is readily interfered with, pain or 
 stiffness is so constantly produced by a draught of cold air, 
 and subsides so soon after reaction has taken place, that we 
 are bound to admit its intimate connection with temporary 
 suspension of cutaneous action.* Moreover, rheumatism is so 
 common among persons suffering from renal disease, and other 
 complaints accompanied by a harsh, inactive condition of the 
 skin, that it is impossible not to connect its appearance, under 
 such circumstances, with the cessation of free cutaneous 
 transpiration. 
 
 The means which nature adopts for its relief, and the cir- 
 cumstances which attend its imperfect development, are also 
 
 ' This instructive fact may appear at first sight to countenance the hypoth- 
 esis of cold as the universal cause of rheumatism. But, in rcialily, ic will 
 bear no such construction. For although the poison which produces the local, 
 symptoms of the disease is in all instances the same, it is necessarily small 
 and definite in quantity when attributable solely to checked perspiration, and; 
 the symptoms, therefore, to which it gives rise must, and do gradually subside 
 from the time when the function of the skin is re-established. But it is noto- 
 rious, that in rheumatism, the development of free cutaneous action has seldom 
 much immediate influence in arresting the symptoms. This arises from the 
 fact, that the poison in these cases is constantly generated de novo in the 
 system, and its production being dependent on many contingent circumstances, 
 its amount is indefinite, and the symptoms therefore produced through its 
 agency are uncertain and variable in duration. 
 4
 
 42 INTRODUCTION. 
 
 suggestive of a relationship between rheumatism and cutaneous 
 secretion. No sooner is a person attacked by the disease than 
 excessive perspiration is set up, as if with the view of getting 
 rid of some peccant matter, and the secretion is most profuse 
 at the very part where local inflammation is taking place. ^ If 
 the perspiration be checked, or take place irregularly or im- 
 perfectly, the disease is protracted, and is rarely got rid of until 
 free cutaneous action has been re-established. It is probable, 
 therefore, that in lactic acid we have discovered the actual ma- 
 teries morbi.^ Be this as it may, the ordinary symptons of the 
 disease, no less than the history of its rarer modifications, are 
 calculated to point to some excretion of the skin as the imme- 
 diate cause of rheumatic inflammation. 
 
 One other point, in connection with this subject, is well de- 
 serving of attention, I mean the specific nature of the poison 
 which constitutes the essence of rheumatism. If the matter, 
 which excites rheumatic inflammation and produces the other 
 symptoms of the disease, be in all cases the same, or, in other 
 words, of a peculiar and specific character, it follows that 
 nothing can give rise to rheumatism, properly so called, unless 
 it have the power, either directly or indirectly, of producing 
 this poison in the system. No point in the whole course of 
 medical inquiry is more fully established, than that diff'erent 
 poisons have separate modes of action, and produce each its 
 own peculiar efi'ect.^ What weight, for instance, would be 
 
 1 I am not aware of having met with this remark in books : and as the seat 
 of the inflammation is often the driest spot in the body, its accuracy may, per- 
 haps, be questioned. It may be well, therefore, to point out the source of this 
 apparent contradiction, which arises from the different condition of the part at 
 different periods of the disease. When a spot is just beginning to be painful, 
 then it is, before the circulation is much impeded, that excretion will there be 
 found so abundant; whereas, if no obscrvaiion be made until progressing in- 
 flammation has greatly retarded the circiilatiou, excretion from the part is 
 almost necessarily arrested. 
 
 * Dr. C. J. B. Williams, among others, expresses his belief in the origin of 
 rheumatism from a poison, probably lactic acid, in the system. (" Principles 
 of Medicine," p. 116.) 
 
 " The relative bearing of cause and effect is the grand physical principle 
 which alone makes medicine worthy of our study, for if it be supposed that 
 agents capable of acting in the human body have not each their definite mode
 
 INTRODUCTION. 43 
 
 attached to the testimony of a man, who stated that he had 
 known the poison of glanders give rise to liydrophobia, or that 
 of measles to small-pox ? Yet in what disorder are the gene- 
 ral phenomena more striking, and the local effects more singu- 
 lar and remarkable, than in acute rheumatism ? A peculiar 
 and specific character is so clearly stamped on this disease, that 
 no one will attempt to question it ; few on due consideration 
 will deny its dependence on a poisonous matter in the system ; 
 all, therefore, ought to agree as to the specific nature of that 
 poison. Bat, in defiance of. those very laws, the due apprecia- 
 tion of which alone makes any study a science, rheumatism has 
 been referred to a dozen different causes, and inferentially at 
 least to as many different poisons. It has been attributed to 
 checked or deficient perspiration, to exposure to cold or to 
 malarious exhalations, to indigestion and imperfect assimila- 
 tion, to defective or perverted uterine action, to the ill perform- 
 ance of the renal functions, to plethora, and to debility ; to one 
 cause or to another, as the history of the case or the appearance 
 of the patient may at first sight have seemed to warrant. 
 Now I will venture to assert, that although a dozen different 
 predisposing causes may tend to the production of the rheu- 
 matic virus in the system, and a dozen different exciting causes, 
 may each separately promote its action and give rise to the 
 immediate development of the symptoms, yet that the poison 
 which is to produce a regular and determined disorder like 
 acute rheumatism, must be invariably the same, must be m 
 itself peculiar, — specific, as giving rise to a specific affection. 
 
 Dr. Todd has suggested, that disordered uterine secretions 
 may be an occasional cause of rheumatism. lie conceives 
 "that the secretions of the uterus, if of an unhealthy char- 
 acter, and not duly thrown off, may be absorbed into the cir- 
 culation and contaminate the blood, producing symptoms of 
 
 of action, we caa neither determine tlie seat and course of any given disorder 
 nor judge of tlie operation of remedies ; whereas, if the definite action of causes 
 be allowed, we arc enabled to determine, within certain limits, the course, 
 symptoms, and pathological phenomena which result from the action of any 
 known agent." (Dr. Williams's Introduction to a " Treatise on Morbid 
 Poisons.")
 
 44 INTRODUCTION. 
 
 greater or less urgency, according to the nature and quantity 
 of the morbid secretion which may have been absorbed."' 
 
 Now, I am ready to admit, that nothing so easily deranges 
 the whole female economy, produces more perverted actions in 
 the system, and therefore tends more directly to the genera- 
 tion of the peccant matter of rheumatism, than does disordered 
 uterine action. But if a certain product of faulty assimilation 
 be at once the essence and cause of rheumatism, (and Dr. Todd 
 himself has adduced powerful arguments in favor of such a 
 supposition,) then the retained or altered secretions of the 
 uterus cannot give rise to the same phenomena, unless they be 
 
 1 " On Rheumatism," p. 149. In support of his position, Dr. Todd cites a 
 case in which a state of protracted araenorrhcca, painful menstruation, and dis- 
 ordered uterine function was entirelj- relieved by the occurrence of a paroxysm 
 of acute rheumatism. The individual in whom these symptoms occurred was 
 a country girl, 23 years of age, who had come to town about twelve months 
 previously. While in the country she had exhibited well-marked symptoms 
 of a rheumatic tendency, having suffered from wandering rheumatic pains i 
 and when she came to London the rheumatic symptoms increased, her health 
 began to fail, and after a time the catamenia ceased. In about si.x weeks after 
 this she began to suffer from severe uterine pains, which continued for about 
 five months, when an attack of acute rheumatism supervened, and all her 
 symptoms disappeared. 
 
 The case is interesting, from the clear evidence adduced of the protracted 
 existence of the rheumatic diathesis, from the lengthened premonitory indica- 
 tions of its ultimate development, and from the clear proof afforded, that the 
 uterus may be affected by the irritation of the rheumatic poison as well as the 
 heart and other parts of the body. But the inferences drawn from it by Dr. 
 Todd appear to me inconsistent with the recorded facts. So far from dis- 
 ordered uterine secretion having been the cause of the rheumatic symptoms, 
 clear evidence is offered of a strong rheumatic tendency at a time when the 
 uterine functions were in no way disordered, for she had suffered from rheu- 
 matic pains in the country when she was otherwise in good health, and her 
 health had begun to fail before the catamenia ceased. My interpretation of 
 the case would be, that before coming to town she had acquired a strong rheu- 
 matic tendency, and that, when after reaching London, her general health 
 gave way, the functions of the uterus became disturbed, the monthly periods 
 eeased, and the rheumatic virus, which is peculiarly prone to affect any part 
 which is functionally deranged, attacked the womb, and gave rise to the ute- 
 rine pain and its attendant symptoms. The pains she suffered were truly 
 rheumatic, and were to be cured, as Dr. Locock has suggested, in similar cases, 
 by guaiacum, colchicum, or whatever may tend to relieve the rheumatism, and 
 in this case were actually relieved by the full development of acute rheumatism, 
 and the consequent elimination of the rheumatic poison, the source of all her 
 previous suffering.
 
 INTRODUCTION. 45 
 
 identical in nature with this said product of mal-assimilation ; 
 and to this, analogy would lead us to demur. 
 
 But although a specific poison, generated in the system as 
 the result of faulty raetamorphic action, is the primary or prox- 
 imate cause of rheumatism, and constitutes the actual materies 
 morbi, yet many agencies may conduce to the formation of the 
 poison and to its retention in the system, and many circum- 
 stances may render the body peculiarly susceptible of its influ- 
 ence. These are the predisposing and exciting causes of the 
 disease. Of all such causes, an inherited rheumatic taint is 
 unquestionably the strongest. It exerts its influence, slowly 
 perhaps, but surely ; and few who have succeeded to this unfor- 
 tunate inheritance, but at some period of their life exhibit 
 symptoms of that peculiar state of system which has been 
 recognized under the title of the "rheumatic diathesis." 
 Thus, many varieties of functional disturbance, many forms of 
 hepatic and uterine derangement, and those diseases of the 
 kidney connected with albuminous urine,^ by impairing the gen- 
 eral health, perverting the functions of nutrition and secretion, 
 and interfering, more or less, with the skin's action, may be- 
 come active agents in the production of this predisposition. 
 Their morbid effects are not confined to the liver, the uterus, 
 or the kidneys : one part of the animal economy hinges so 
 closely on the other, that local mischief occasions general dis- 
 turbance, and under certain circumstances appears to induce a 
 state of system favorable to the generation of rheumatic poison ; 
 a state of system arising, be it observed, not as a direct and 
 immediate consequence of suspended secretion, but as a sequel 
 of perverted function gradually taken on by the system gen- 
 erally, in consequence of imperfect or morbid local action.^ 
 
 • This is a powerful predisposing cause of the disease, inasmuch as not only 
 is the skin's action interfered with, but the diseased organs are unable to act 
 vicariously, and so to assist in eliminating the poison. 
 
 2 The phenomena of gonorrhoea afford an admirable example of how local 
 diseases may gradually give rise to general derangement of the system, and so 
 to the production of the peccant matter of rheumatism. So constantly is 
 rheumatism associated with gonorrhoea, that many rheumatic persons, on con- 
 tracting that disease, can predict with amazing accuracy the accession of
 
 46 INTRODUCTION. 
 
 In like manner cold, by exercising a depressing influence on 
 the system, and thus producing functional derangement, may 
 contribute largely to the generation of the rheumatic poison, 
 and so may damp and malarious exhalations. Excessive venery 
 and long-continued debauchery are in the same way frequently 
 productive of rheumatism, and so is immoderately protracted 
 lactation. Many a woman suffers, soon after her confinement, 
 if followed by great constitutional exhaustion, or as the reward 
 of her folly, in inordinately protracting the period of suckling. 
 Chomel, who observed the frequency of the disease shortly after 
 delivery, refers its appearance, under such circumstances, to 
 the sudden suppression of the lochial discharge. Such an ex- 
 planation, however, does not hold good. It is diflBcult to con- 
 ceive how the lochia can have any connection with rheumatism, 
 except as producing functional derangement, and so possibly 
 tending to favor the development of the rheumatic virus in the 
 system ; and I have myself seen several cases in which the 
 disease did not appear until some time after the lochial dis- 
 charge had naturally and entirely ceased ; until, in fact, im- 
 paired nutrition had begun to follow on the wear and tear 
 sustained by the constitution during delivery, or during lacta- 
 tion carried beyond the patient's strength. 
 
 These, then, and many other instances Avhich might be quoted, 
 may be fairly included under the general expression, that any- 
 thing which disturbs the general health, and gives rise to a state 
 of impaired assimilation, becomes, under certain circumstances, 
 a predisposing cause of rheumatism.^ The only way, there- 
 fore, of preventing or counteracting it, is by noting the earliest 
 
 rheumatic inflamraation of their joints, and not unfrequently of inflammation 
 of the conjunctiva, such as is apt to accompany rheumatism in unhealthy or 
 cachectic persons. 
 
 ' I am glad to quote, in confirmation of my opinion, some admirable remarks 
 by Dr. Taylor, of Huddersfield. '' I believe," he says, " the really efficient 
 cause, to be such a change in the constitution of the body, chiefly, perhaps, of 
 the fluids, as is more or less slowly induced, under the influence of circum- 
 stances unfavorable to health, but often operating imperceptibly, and discov- 
 ered only by very careful investigation ; I allude more particularly to impro- 
 prieties, not necessarily gross ones, in diet, clothing, or labor, and to undue 
 habitual exposure to cold or damp, or anxiety of mind, as well as to other 
 agencies which gradually undermine the health." ("Med,-Chir.," vol. xxviii, 
 pp. 462-3.)
 
 INTRODUCTION. 47 
 
 symptoms of local disturbance, and taking active measures to 
 prevent its continuance, by carefully attending to the general 
 health, and lastly, as the skin is the peculiar emunctory of the 
 poison, by promoting free cutaneous action. 
 
 The exciting causes of the disease are extremely numerous, 
 but not being peculiar to rheumatism, they hardly call for 
 comment or observation. Suffice it to say that when the rheu- 
 matic poison is present in the system, any disturbing circum- 
 stance, even of temporary duration, such as over-fatigue, 
 anxiety, grief, or anger, by rendering the system more suscept- 
 ible of its influence, may prove the accidental or exciting cause 
 of the disease, and that exposure to cold or to atmospheric 
 vicissitudes is almost certain to induce an attack. 
 
 The more the history of rheumatism is studied, the more 
 closely and carefully its details are examined, the more obvious 
 does it become that the disease does not result from the local 
 agency of cold.' But when after long-continued exposure, 
 cold begins to exercise a depressing influence on the system, it 
 at once opens the door to mal-assimilation, and thereby, if a 
 rheumatic tendency exist, to the formation of the rheumatic 
 poison ; and when that poison is present in the system it assumes 
 a further noxious potency ; it then not only exercises a depress- 
 ing influence on the system, and thereby renders it more sus- 
 ceptible of the irritation of the poison, but by checking free 
 cutaneous action it stops the natural outlet of the morbific 
 agent, promotes its accumulation in the system, and thereby 
 tends directly to the development of the disease. 
 
 Thus it would appear that cold and other external agencies 
 are only predisposing and exciting causes of rheumatism, and 
 that the primary, proximate, or essential cause of the disease, 
 is the presence of a morbid matter in the blood, generated in 
 
 ' '• Cold is a frequent cause of rheumatic fever, and produces its effects on 
 the joints by interference with the general business of nutrition, not by local 
 influences directly prejudicial to their structure. These organs are never more 
 carefully protected from cold than during the great heats and sweats of the 
 rheumatic fever, yet one large joint after another becomes inflamed in sequel 
 of the constitutional disorder during a period of time extending, it may be, 
 over weeks, from the invasion of the joint first attacked to that of the last." 
 (" On the true Character of Acute Rheumatism," by Dr. J. A. Wilson, " Lan- 
 cet," 1844, p. 193.)
 
 48 INTRODUCTION. 
 
 the system as the product of a peculiar form of mal-assim- 
 ilation — of vicious metamorphic action. This poison it i? 
 which excites the fever/ and produces all the pains and local 
 inflammations which are often found associated in an attack 
 of rheumatism. If the rheumatic virus be present in small 
 quantity only, it may cause little more than wandering pains 
 in the limbs, and may scarcely induce any perceptible fever, 
 while if it exist in larger quantities, it rarely fails to cause 
 febrile disturbance, and excite inflammation in various parts 
 of the body. In that respect, however, its effects are found to 
 vary in different cases. Sometimes, though it cause great 
 febrile excitement, its local agency may be confined to the 
 production of external articular inflammation ; at others it 
 may fail to produce arthritis, but may give rise to acute 
 inflammation of the heart ; and at others, again, carditis may 
 be only one out of several internal inflammations which it sets 
 up coincidently with extensive articular mischief. Moreover, 
 there appear good grounds for believing that, as in some cases 
 it gives rise to excessive febrile disturbance for days prior to 
 the accession of articular inflammation, and repeatedly without 
 exciting inflammation of the heart, so in certain instances it 
 may excite the peculiar train of symptoms whereby rheumatic 
 fever is characterized, without producing, from first to last, the 
 slightest concurrent local inflammation, whether of the joints, 
 or of the heart, or any other organ. ^ 
 
 ' The fever in some instances may be aggravated by the local inflam- 
 mations, but it is essentially independent of them, and is frequently well 
 developed long before their commencement. 
 
 ^I have met with several instances in which the development of rheumatic 
 fever has been complete, and in which, nevertheless, the articular and other 
 local symptoms have been slight and evanescent. One case of this sort is 
 reported in Cap. VIII of this work. In another, in which no articular inflam- 
 mation occurred until the eighth day of the attack, the fever was from the first 
 most severe and characteristic. Dr. John Taylor has reported similar instances, 
 and Dr. Graves ("Clinical Medicine," p. 914) has met with "several well- 
 marked cases of individuals liable to rheumatic fever, and who had previously 
 8uff"ered from attacks of fever with arthritis in the usual form, who subse- 
 quently, on exposure to cold, were seized with symptoms of pyrexia, which in 
 intensity, duration, and every other particular were identical with these former 
 fevers, save and except that from beginning to end, not a single joint was 
 inflamed."
 
 CHAPTER II. 
 
 ON THE UEREDITARY CHARACTER OF RHEUMATISM. 
 
 In the Introductory Chapter, I have directed attention to 
 a certain state of constitution in which a strong tendency to 
 rheumatism exists as a sequel of disordered or perverted nutri- 
 tion. To determine the conditions which favor the production 
 of such a state, to ascertain the laws which govern its develop- 
 ment, and to discover, if possible, some means of checking or 
 arresting its progress, is a matter of some importance ; and I 
 will, therefore, endeavor to bring together various circum- 
 stances which appear to throw some light on the subject. 
 
 One of the most suggestive, and for practical purposes the 
 most important, is the hereditary character of the disease 
 under consideration. Rheumatism, like gout, is distinctly 
 hereditary. From father to son its seeds are transmitted and 
 bear fruit in exact proportion to the degree in which circum- 
 stances prove favorable to their growth. In those persons 
 who are exposed to atmospheric vicissitudes, and pay little 
 heed to their general health, the soil is congenial and admi- 
 rably adapted for the full development of the disease ; mal- 
 assimilation is very likely to occur; the skin performs, its 
 function irregularly ; and the poison thus generated and 
 retained in the system can hardly fail to bear fruit to perfec- 
 tion. Not only will a rheumatic diathesis be established early, 
 but the disposition will increase until it issues in a paroxysm 
 of acute rheumatism. 
 
 In others who are attentive to their general health, and 
 carefully avoid unnecessary exposure, the soil is uncongenial, 
 and the seeds either lie dormant, or fail to attain their perfect 
 growth, for lack of sufficient nourishment. The same tendency
 
 50 HEREDITARY DISPOSITION TO RHEUMATISM. 
 
 to mal-assimilation may exist, but so much caution is observed, 
 and such iininediate steps are taken on the slightest appear- 
 ance of functional disturbance, to check or arrest the progress 
 of disease, that no root can be taken before that element, 
 which is essential to the growth of the seed, is eliminated or 
 got rid of from the system. Thus, although a disposition to 
 rheumatism may arise, and may be evinced by the presence of 
 wandering rheumatic pains, yet, with due care, a paroxysm of 
 rheumatic fever may be warded off, and the tendency to the 
 disease, for a time at least, got rid of. There is, however, 
 cause for serious apprehension when rheumatic symptoms have 
 begun to manifest themselves, inasmuch as, however slight or 
 trivial in their character, they are certain evidences of a con- 
 stitutional change, which may eventually terminate in a par- 
 oxysm of acute rheumatism ; and the least want of caution, 
 the least exposure, may induce an immediate and violent 
 attack. 
 
 The hereditary disposition to rheumatism has been often 
 overlooked or disregarded. Its existence, however, to a 
 remarkable degree, does not admit of reasonable doubt. I 
 have known several families who, for two generations, have 
 been grievously tormented with the disease, and in sundry of 
 whose members it has repeatedly appeared in its most acute 
 and terrible form. Circumstances not unfrequently concur to 
 render our efforts to trace its hereditary character difficult, 
 and often to make them unavailing, yet we cannot but feel 
 surprised at the large number of cases in which its existence 
 can be clearly ascertained. The records of the Consumption 
 Hospital exhibit the operation of an inherited predisposition 
 in little more than 24 per cent, of the cases there admitted ;' 
 and the annals of insanity supply data to prove that its influ- 
 ence obtains in less than 13 per cent, among the inmates of 
 lunatic asylums ;^ whereas, among the rheumatic patients 
 admitted into St. George's Hospital, I have traced it in 
 
 1 See " First Medical Report of the Consumption Hospital." 
 * For tables illustrative of this subject, see the " First Medical Report of the 
 Consumption Hospital at Brompton."
 
 HEREDITARY TENDENCY TO RHEUMATISM. 51 
 
 nearly 29 per cent. ;^ and M. Chorael distinctly ascertained it 
 in half the cases admitted into the Hotel Dieu.^ Nor is this 
 the only one evidence which can be offered in its favor. M. 
 Roche^ has expressed his firm belief in its hereditary ten- 
 dency ; and Dr. Maclcod/ and other physicians of eminence 
 in this country, have arrived at the same conclusion. More- 
 over, this hereditary tendency exists almost invariably in the 
 cases which are earliest and most fully developed f and we, 
 therefore, cannot fail to join M. Chomel in exclaiming, that 
 the just and striking expression of Baillon^ — "ut bonorum 
 haereditates, ita et morborum successiones ad posteros prove- 
 niunt" — most fully applies to rheumatism. 
 
 I would not, however, be understood to imply that rheuma- 
 tism is always hereditary. Doubtless a rheumatic diathesis 
 may be acquired under various circumstances, and my observ- 
 ation only goes to the extent, that a person who from youth 
 has suffered severely from rheumatism, will probably transmit 
 a rheumatic tendency to his offspring. 
 
 At what age, then, is this diathesis developed ? Or, to put 
 the question in a more practical form, — At what age does rheu- 
 matism generally appear ? 
 
 It will be seen by reference to Table II, appended to this 
 Chapter, which gives the result of Dr. Macleod's and M. 
 Chomel's experience, as well as my own observations on the 
 subject, that the usual age for the development of the acute 
 disease, is from about the period of incipient puberty, until the 
 powers of the system begin, in some measure, to fail, very few 
 cases occurring before the age of 15, and comparatively few 
 after the age of 50. 
 
 In St. George's Hospital . 246 71 
 
 Other Patients . 84 25 
 
 2 "Lemons tie Clinique Medicale," torn, ii, p. 126. 
 
 •'' " Dictionnaire de Mudecine et de Cliirurgie pratiques." 
 
 ♦ " On Rheumatism," p. 3. 
 
 •'' See Table I, appended to this Chapter. 
 
 * " Ballonii Consiliorum Medicinalium," lib. iii. 
 
 28-8 
 29-7
 
 52 AGE OF DEVELOPMENT. 
 
 It must not be supposed, however, that rheumatism is con- 
 fined to the ages just specified. Our sensations teach us, 
 that we grow more rheumatic as we grow older ; and the result 
 of extended medical observation shows, that the disease, though 
 not occurring in an acute form in advanced life, does, never- 
 theless, invade our stiffening limbs more commonly than some 
 persons have been inclined to admit. ^ The cause of the differ- 
 ence in the type of the disorder at different ages, admits of 
 satisfactory explanation. As rheumatism is due to the pres- 
 ence of a materics morbi, generated during the destruction and 
 re-formation of the tissues, processes which take place with unu- 
 sual activity during early life, and more slowly as age advances, 
 it follows that mal-assimilation is more likely to be attended 
 with an abundant formation of the rheumatic poison, and there- 
 fore, with greater severity in the rheumatic symptoms, in early 
 than in advanced life. Moreover, it appears to be a merciful 
 law of Providence, that as man's age advances, and the system 
 becomes less able to bear up against the wear and tear of 
 severe illness, its natural susceptibility to acute disorders should 
 be materially lessened. It thus becomes comparatively insen- 
 sible to the poison of scarlatina and marsh miasmata, and to 
 the influence of many other noxious matters. So also in regard 
 to the effect of local injuries. The blow which, in a young 
 man, would have given rise to acute local inflammation and 
 symptomatic fever, will, in the old man, probably induce little 
 more than temporary pain and stiffness, or should inflammation 
 be set up, it will generally be of a subacute character. Thus, 
 the development of the acute form of rheumatism, in advanced 
 life, is rendered improbable, not only by the source and nature 
 of its materies morbi, but by reference to other febrile and 
 inflammatory affections.^ 
 
 A parity of reasoning, however, would lead us to anticipate 
 
 » See Tab. ITI, p. 58. 
 
 2 The diminished susceptibility to irritation exhibited by the system gen- 
 erally, is displayed most strikingly in the fibrous textures, the usual seat of 
 rheumatic inflammation. The great Bichat says, " Dans les vieillards, le sys- 
 teme fibreux devient de plus en plus dense et serre."
 
 CAUSES WHICH MODIFY THE FORM OF THE DISEASE. 53 
 
 a more constant tendency to the formation of the poison in 
 advanced years, and a more frequent occurrence of symptoms 
 indicating its presence in the system. And such is, indeed, 
 too frequently the case. So common is some degree of mal- 
 assimilation in advanced life, and so constant the tendency to the 
 formation of rheumatic poison, that a greater or less amount 
 of it is almost always present. Its effects are evident on the 
 slightest exposure, on the slightest exciting cause, for pain 
 ensues, wandering from limb to limb, often fixing on some one 
 in particular, and not unfrequently producing effusion into the 
 joint, with temporary thickening of the tendons in its imme- 
 diate vicinity. Thus, months will sometimes pass away, point- 
 ing with the heavy finger of suffering to the poisoned condition 
 of the circulation. In youth this is very seldom the case. The 
 susceptibility of the system does not long remain unmoved : 
 either the excretory organs are stimulated to thro*' out the 
 morbific matter ; or, if not, the constant presence of an irri- 
 tant matter, which has accumulated sufficiently to give rise to 
 pain, soon rouses the system to action, symptomatic fever is 
 set up, and ushers in an attack of acute or subacute rheu- 
 matism. 
 
 Sometimes, however, a person advanced in years does suffer 
 from acute rheumatism, while, on the other hand, a person not 
 yet past his prime is occasionally tormented with the chronic 
 form of the disease. And the phenomena observed in the 
 cases alluded to, entirely confirm the view I have taken. In 
 the former instances the patient is invariably vigorous for his 
 age, active, and otherwise of a strong constitution — one, there- 
 fore, whose system is still susceptible of irritation, and still 
 prone to set up acute inflammatory action ; while, in the 
 latter, the poison is either generated in small quantity, as is 
 evidenced by the slightness of the functional disturbance, or 
 the patient is of a sluggish, inactive disposition, and phleg- 
 matic temperament — one, therefore, whose system is difficult to 
 rouse so as to set up an acute paroxysm of the disease. 
 
 I maintain, then, that the liability to rheumatism increases
 
 54 AGENCIES INFLUENCING THE FORM OF THE DISEASE, 
 
 with advancing years ; that, in early childhood, it is very 
 uncommon, but, in adult life, one of the commonest and most 
 troublesome complaints which flesh is heir to; that although 
 the chronic form of the disease rarely appears in the irritable 
 state of the system which occurs in youth, and the acute form 
 seldom arises when the irritability of the constitution is blunted 
 by age, yet that the variety in form depends, not on any differ- 
 ence in the proximate cause of the disease, nor on any differ- 
 ence in the character of the materies morbi, but on the quan- 
 tity of the poison present, on the nature of the constitution to 
 be acted on by it, and on the influence exerted by age and its 
 accompanying changes in the system. Such are the agencies 
 which modify the form which the disease assumes, and the 
 result of their operation will be seen by an inspection of Table 
 III, appended to this Chapter.' 
 
 It has #)een asserted, that the occurrence of an acute attack 
 of the disease tends to strengthen the disposition to rheuma- 
 tism. But this is certainly not the case, A paroxysm is evi- 
 dently but an effort of the constitution, and generally for the 
 time an effectual effort, to get rid of the poison ; and it is highly 
 improbable that such an action should tend to perpetuate a 
 diathesis, the effects of which itself is set up to counteract. If 
 such were the case, the victim of a well-developed attack of 
 the disease would inevitably be a martyr to rheumatism for the 
 remainder of his life ; whereas the occurrence of a single acute 
 attack is by no means uncommon when exciting causes are 
 subsequently avoided, and the general health is carefully at- 
 tended to.^ Moreover, it is impossible, on such a supposition, 
 to account for the rare occurrence of rheumatic symptoms 
 shortly after the subsidence of a well-developed paroxysm, and 
 for the long period which usually intervenes between any two 
 acute attacks ; while, on the other hand, the fact that if the 
 paroxysm be irregular and ill developed, rheumatic symptoms 
 
 1 See page 58. 
 
 *" Enfin quclques examples preuvent, que le Rheutnatisme peut ne se mon- 
 trer q'une fois dans tout le cours de la vie." (Chomel, op. cit., p. 124.)
 
 CLASS OF PERSONS AND THE SEX AFFECTED. 55 
 
 very commonly remain behind, points very decidedly to the 
 opposite conclusion. 
 
 But when once a paroxysm has been fully established, there 
 is too much reason to dread its recurrence at some future 
 period, for it is a certain sign of a tendency to the formation of 
 the rheumatic poison, of the proneness of the system to suffer 
 from its influence, and of its power to set up those actions which 
 constitute acute rheumatism. Moreover, in ordinary cases, 
 but little care is taken, after recovery from such an attack, to 
 guard against a similar invasion in future. The disease is 
 looked upon as the effect of cold ; and, therefore, to use the 
 common phraseology, "when it is fairly cured," no treatment 
 is subsequently adopted ; no means are taken to improve the 
 general health ; the patient having for the time got rid of the 
 materies morbi, feels as well, or even better than he had done 
 for weeks or months previously, and, ignorant of the real cause 
 of the disease, is unwilling, even should his medical attendant 
 recommend it, to subject himself to further treatment. Yet 
 this is just the time when medical interference is most effective 
 in correcting that unhealthy state of assimilation on which the 
 existence of rheumatism depends, and which, if not immediately 
 arrested, will probably pass from bad to worse, until it issues 
 again in a paroxysm of the disease. 
 
 The class of patients and the sex most obnoxious to rheuma- 
 tism, call only for a passing remark, as a slight consideration 
 as to the cause of the disease will suffice to point out its more 
 favorite victims. Those persons are naturally the chief suffer- 
 ers who, through want and privations, irregularity of life, and 
 neglect of their general health, are rendered most liable to that 
 state of mal-assimilation whereby the materies morbi is pro- 
 duced ; and who, again, from the nature of their occupations, 
 are most exposed to atmospheric vicissitudes, and to other 
 exciting causes of the disease. Subject to such modifying in- 
 fluences as these, all classes of society and both sexes are 
 almost equally liable to its invasion ; but if the question be 
 viewed solely in reference to its actual occurrence, rheumatism 
 will be found more prevalent in the lower than in the upper
 
 56 INFLUENCE OF CLIMATE AND SEASON. 
 
 ranks of society ; and in its acute, no less than in its chronic 
 forms, more frequent among men than among women.' 
 
 Climate and season are generally supposed to have a power- 
 ful influence over the production of rheumatism. Except, 
 however, as predisposing and exciting causes, it has been shown 
 already that they can exercise no such power ; and the influ- 
 ence they do exert, as proved by experience, is just such as 
 might be expected from the nature of the case. If the disease 
 be dependent on the presence of a materies morbi in the blood, 
 a matter of which the skin is the peculiar emunctory, we should 
 hardly expect it to occur so frequently in summer, when the 
 skin is acting freely, as at that season of the year when cu- 
 taneous action is comparatively sluggish. For the same reason 
 we should expect it to prevail chiefly in cold, damp, and vari- 
 able climates, for when moisture lends its aid to cold in de- 
 pressing the system generally, and thereby favoring the 
 generation of the poison, as also in checking perspiration, and 
 thus preventing its escape from the system, then we should 
 consider all things favorable for the development of rheumatic 
 symptoms. Now facts are strictly in keeping with these deduc- 
 tions. It is not in the most inclement seasons nor in the coldest 
 climates that rheumatism is most prevalent, but at those seasons 
 
 Males. Females. 
 
 ' Out of 623 patients suffering from rheumatism admitted under 
 my care at St. George's Hospital, during the seven years 
 ending July 31sL, 1855, there were, 426 197 
 
 Out of 1014 rheumatic patients admitted into St. George's Hos- 
 pital, under the care of the physicians, during the four years 
 ending December 31st, 1848, 666 348 
 
 Out of 751 rheumatic patients who came under the care of Sir 
 Gilbert Blane, at St. Thomas's Hospital, (" Med.-Chir. 
 Trans.," vol. vi) • . .547 204 
 
 Total number of cases 2388, of which .... 1539 • 749 
 Acute Rheumatism. 
 Out of 289 cases of acute rheumatism admitted into St. George's 
 
 Hospital during the four years ending December 31st, 1848, 151 138 
 
 Out of 136 cases of acute rheumatism recorded by Dr. Latham, 
 
 ("Clinical Medicine," p. 143) 75 61 
 
 Total number of cases 425, of which .... 226 199
 
 STATISTICAL REPORTS. 
 
 57 
 
 and in those climates remarkal)le for damp and variable 
 weather.^ The disease occurs less frequently in the frosty 
 month of December, than in the warmer but relaxing "weather 
 of May,^ and it is not so prevalent in the cold climate of Nova 
 Scotia and New Brunswick as at the Cape of Good Hope, the 
 land of heaths and geraniums.^ It further appears from ob- 
 servations made in India by Mr. Malcolmson, that, in its acute 
 form at least, the disease is very rare within the tropics, and 
 as we draw toward the poles the symptoms of acute rheuma- 
 tism are almost unknown.* 
 
 Table I. 
 
 Table exhibiting the strong hereditary tendency which exists among those cases of 
 Acute Rheumatism which are earliest developed. The cases were all admitted into 
 St. George's Hospital between the 1st of January, 1845, and the 1st of May, 
 1848. 
 
 Age. 
 
 Total num- 
 ber of cases. 
 
 Hereditary. 
 
 Not 
 Hereditary. 
 
 Uncertain. 
 
 I have no Note 
 on tlie subject. 
 
 Under 15 
 
 15 
 
 8 
 
 6 
 
 1 
 
 _ 
 
 15 to 20 
 
 58 
 
 22 
 
 31 
 
 3 
 
 2 
 
 20 25 
 
 63 
 
 19 
 
 36 
 
 3 
 
 5 
 
 25 30 
 
 50 
 
 13 
 
 26 
 
 5 
 
 6 
 
 30 35 
 
 22 
 
 .5 
 
 13 
 
 1 
 
 3 
 
 35 40 
 
 17 
 
 3 
 
 8 
 
 2 
 
 4 
 
 40 45 
 
 9 
 
 — 
 
 7 
 
 — 
 
 2 
 
 45 50 
 
 9 
 
 1 
 
 7 
 
 — 
 
 1 
 
 50 55 
 
 1 
 
 
 
 1 
 
 
 
 
 
 55 60 
 
 2 
 
 — 
 
 2 
 
 — 
 
 — 
 
 246 
 
 71 
 
 137 
 
 15 
 
 23 
 
 In all the four cases recorded as hereditary, iu patients over the age of 35, 
 the disease had manifested itself several times previously ; in one, indeed, no 
 ^ess than four times. Two of those who were between the ages of 30 and 35 
 had experienced two previous attacks, and two others had ouce before under- 
 
 1 See Table IV, appended to this Chapter, p. GO. 2 jbjQ 
 
 * Out of luOO patients admitted into the Military Hospitals in different parts 
 of the world, there are 29 rheumatic patients in Jamaica, 30 in Nova Scotia or 
 New Brunswick, 50 in Great Britain, and 57 at the Cape of Good Hope, giving 
 a proportion of less than three per cent, in the two former places, and of five 
 per cent, and upwards in the two latter. The numbers are quoted in Craigie's 
 "Practice of Physic." 
 
 * Le Rheumatisme se presente rarement pres de I'equateur et des poles et 
 devient successivement plus commun a mesure qu'on s'eloigne de ces regions, 
 et regne surtout dans les Zones temperees. (Chomel, op. cit., p. 4G2.)
 
 53 STATISTICAL REPORTS ON THE 
 
 gone a similar infliction. But even taking the Table as it stands, it exhibits 
 
 the influence of an inherited predisposition in — 
 
 1 out of every 1-9 patients under the age of 15 
 1 " 2-6 " " 20 
 
 1 " 3-5 " between the ages of 20 and 30 
 
 1 " 6-6 " over the age of 30 
 
 Mons. Chomel's experience coincides with this. He says, (op. cit., p. 135,) 
 
 " II est bon de remarquer que dans les cas ou I'enfance est ainsi atteinte contre 
 
 la r^gle c'est presque toujours sous la triste influence de rhcrcdite." 
 
 Table II. 
 
 Table exhibiting (he result of various Observations as to the Age at which Acute 
 Rheumatism most commonly occurs. 
 
 Of 73 patients admitted into the Hospital de la Charite, at Paris — 
 2 were first attacked before the age of 10 
 35 " between the ages of 15 and 30 
 
 22 " " '• 30 " 45 
 
 1 " •' " 45 " 50 
 
 1 " after the 60th year. 
 
 (Chomel, op. cit., p. 134.) 
 In this Table, however, M. Chomel has included both gout and rheumatism, 
 so that it shows too high an average in the latter years. 
 
 Of 199 patients suffering from acute rheumatism — 
 
 8 were between the ages of 10 and 15 
 180 " " 15 " 40 
 
 10 " " 40 " 55 
 
 1 exceeded the age of 55. 
 
 (iMacleod on "Rheumatism," p. 152.) 
 
 Of 239 patients suffering from acute rheum.atisra, admitted into St. George's 
 Hospital, during the four years ending December 31st, 1848 — 
 16 were between the ages of 5 and 15 
 241 " " 15 " 40 
 
 25 " " 40 " 50 
 
 7 had passed the age of 50. 
 In one instance only was the patient under the age of 10. The disease, how- 
 ever, does sometimes occur at a much earlier period of life. I have under my 
 care, at the hospital, a child only 8 years old, suffering from dropsy and dis- 
 eased heart, the result of two attacks of rheumatism, one of which occurred at 
 the age of 2 years and 9 months, and the other at the age of 6 years and 4 
 months ; another child, only twenty months old, was brought to me last year 
 (1855) with several of its joints red and swollen from rheumatic inflammation. 
 Dr. Heberdcn reports " the rheumatism has appeared as early as in a child of 
 4 years old." Dr. Watson relates, ("Lectures," ed. 1, vol. ii, p. 623,) "I have 
 frequently seen it in children, sometimes as early as the third or fourth year ;" 
 and Dr. Davis states, (" Med. -Chir. Review," for October, 1817,) "several cases
 
 OCCURRENCE OF ACUTE RHEUMATISM. 
 
 59 
 
 of acute rheumatism were admitted in children of 3, 4, 5, 6, and 7 j'cars of age 
 and upwards." 
 
 Table III. 
 
 Table o/ 1014 Cases of Eheumatism and Rheumatic Go\U, admitted into St. GeorgeJs 
 Hospital, during the four years ending December Z\st, 1848, shelving the form of 
 the disease, and the age and sex of the Patients. 
 
 Age. 
 
 Acute 
 Rheumatism. 
 
 Subacute 
 Rheumatism. 
 
 Chronic Rheu- 
 matism, inclu- 
 ding Sciatica 
 
 Rheumatic 
 
 Gout. 
 
 TOTAL. 
 
 5tol0 
 
 Men. Women. 
 1 — 
 
 Men. Women. 
 2 — 
 
 Men. Women. 
 
 Men. Women. 
 
 Men. 
 3 
 
 Women. 
 
 10—15 
 
 4 11 
 
 4 '3 
 
 4 2 
 
 — 1 
 
 12 
 
 17 
 
 15—20 
 
 22 45 
 
 17 10 
 
 18 12 
 
 3 6 
 
 60 
 
 73 
 
 20—25 
 
 37 35 
 
 26 10 
 
 37 13 
 
 8 4 
 
 108 
 
 62 
 
 25—30 
 
 31 25 
 
 23 12 
 
 67 12 
 
 5 8 
 
 126 
 
 57 
 
 30—35 
 
 15 11 
 
 13 9 
 
 46 10 
 
 9 7 
 
 83 
 
 37 
 
 35—40 
 
 15 5 
 
 10 4 
 
 37 16 
 
 10 8 
 
 72 
 
 33 
 
 40—45 
 
 9 3 
 
 3 4 
 
 33 5 
 
 12 11 
 
 57 
 
 23 
 
 45—50 
 
 11 2 
 
 5 1 
 
 32 12 
 
 14 3 
 
 62 
 
 18 
 
 50—55 
 
 •) 
 
 2 — 
 
 17 7 
 
 6 7 
 
 27 
 
 14 
 
 55—60 
 
 3 1 
 
 2 — 
 
 26 4 
 
 8 3 
 
 39 
 
 8 
 
 60—65 
 
 1 — 
 
 — — 
 
 4 2 
 
 2 3 
 
 7 
 
 5 
 
 65—70 
 
 — — 
 
 — — 
 
 3 1 
 
 5 — 
 
 8 
 
 1 
 
 70—75 
 
 — — 
 
 — — 
 
 1 — 
 
 
 
 1 
 
 
 
 75—80 
 
 — — 
 
 — — 
 
 1 — 
 
 — — 
 
 1 
 
 — 
 
 151 138 
 
 107 53 
 
 326 96 
 
 82 61 
 
 666 
 
 348 
 
 In this table, however, I am satisfied that many cases are included under the 
 title of Rheumatic Gout, which ought to have been classified under the head 
 of Gout, for later and more experienced observation has convinced me that 
 many cases of pure Gout occur, which an inexperienced eye is unable to dis- 
 tinguish from Rheumatic Gout, and that true Rheumatic Gout is of fiir less 
 frequent occurrence in men than the above table would indicate. Subjoined 
 is a table of the last 285 cases of Rheumatic Gout which have come under my 
 care, whether in hospital or private practice. 
 
 
 
 RHEOMATIC GOUl 
 
 
 
 
 Age. 
 
 Men. 
 
 Women 
 
 Age. 
 
 Men. 
 
 Women. 
 
 Total. 
 Men. Women. 
 
 5tol0 
 
 
 
 1 
 
 45 to 50 
 
 5 
 
 24 
 
 10—15 
 
 — 
 
 3 
 
 50—55 
 
 3 
 
 17 
 
 52 332 
 
 15—20 
 
 3 
 
 14 
 
 55—60 
 
 
 
 9 
 
 
 20—25 
 
 5 
 
 27 
 
 60—65 
 
 1 
 
 7 
 
 
 25—30 
 
 11 
 
 21 
 
 65—70 
 
 — 
 
 2 
 
 
 30—35 
 
 9 
 
 37 
 
 70—75 
 
 — 
 
 2 
 
 
 35—40 
 
 7 
 
 31 
 
 75—80 
 
 
 
 — 
 
 
 40—45 
 
 8 
 
 37 
 
 
 
 
 
 In men, the disease occurs most commonly in sequel of the cachexia in- 
 duced by syphilis and gonorrhoea.
 
 60 
 
 STATISTICAL REPORTS. 
 
 Table IV. 
 
 Table exhibiting the Influence of Season upon the production of Rheumatism. 
 
 Out of 623 rheumatic patients, admitted as out-patients, under my care at 
 
 St. George's Hospital, during the seven years ending July 31st, 1855, there 
 
 occurred — 
 
 In Januar}', 53 ; in February, 54 ; in March, 51 ; in April, 60 . . z=218 
 " May, 57; in June, 48; in July, 52 ; in August, 49 . . . =206 
 
 " September, 54 ; in October, 48 ; in November, 50 ; in December, 47 =199 
 Out of 1014 rheumatic patients admitted into St. George's Hospital, under 
 
 the care of the physicians, during the four years ending December 31st, 1848, 
 
 there occurred in — 
 
 
 Acute. 
 
 Subacute. 
 
 Chronic. 
 
 Elieumatic 
 Gout. 
 
 Total. 
 
 January 
 
 27 
 
 13 
 
 44 
 
 14 
 
 98] 
 
 February 
 
 27 
 
 12 
 
 23 
 
 10 
 
 97 1-3*3 
 
 March . 
 
 28 
 
 18 
 
 36 
 
 15 
 
 April 
 
 23 
 
 15 
 
 27 
 
 11 
 
 76J 
 
 May 
 
 30 
 
 14 
 
 40 
 
 16 
 
 100] 
 
 June 
 
 21 
 
 10 
 
 34 
 
 21 
 
 86 [ooo 
 
 July . 
 
 14 
 
 10 
 
 27 
 
 14 
 
 65 f 328 
 
 August . 
 
 16 
 
 11 
 
 41 
 
 9 
 
 77J 
 
 September 
 
 22 
 
 16 
 
 45 
 
 15 
 
 98] 
 
 October 
 
 27 
 
 11 
 
 37 
 
 5 
 
 80 ,40 
 
 November 
 
 28 
 
 19 
 
 29 
 
 10 
 
 86 (-343 
 
 December 
 
 26 
 
 11 
 
 39 
 
 3 
 
 79J 
 
 289 
 
 160 
 
 422 
 
 143 
 
 1014
 
 CHAPTER III. 
 
 ON THE SEAT OF RHEUMATISM. 
 
 Much difference of opinion has existed among physiologists 
 as to the precise localities or textures of the body which become 
 the seat of pain and inflammation in rheumatism. Some 
 persons hare referred to the muscular structures as the primary 
 seat of the disease, and have maintained that other parts are 
 attacked in consequence of their proximity to those first af- 
 fected. Some have imagined the tendons ta be its primary 
 seat, and some have confined its action to the ligaments ; while 
 others, taking a wider range, have given it a choice among all 
 the fibrous textures of the body. Some, again, unwilling to 
 recognize its constitutional origin, and unable otherwise to ex- 
 plain the frequent shifting of its local symptoms, have suggested 
 the aponeurotic sheaths and the fascise as its seat, and suppos- 
 ing its effects to spread by continuity of surface, have thus 
 endeavored to explain its attacks on various parts of the body. 
 
 Now, lookincr at the diff'erence in these theories, based as 
 they mostly are upon actual, though -not very extended, observ- 
 ation, it might be fairly inferred that no one texture is exclu- 
 sively the scat of irritation in rheumatism ; and the history 
 which has been given of the nature of the disease, borne out 
 by many of its most striking phenomena, completely estab- 
 lishes the correctness of this inference. For if rheumatic 
 inflammation be due to the presence of an irritating matter in 
 the blood, it is obvious, as all parts of the body are supplied 
 by this blood, and are, therefore, equally exposed to its influ- 
 ence, that all must be more or less liable to suff"er. Such is 
 the law respecting the action of poisons in general,^ and such, 
 
 1 '• It is seldom that the action of poisons is limited to one membrane, or 
 organ, or systetu of organs ; the greater number of these noxious agents act on 
 two or more organs, or systems of organs." (Ur. Williams " On Morbid Poi- 
 sons," vol. i, p. 4.)
 
 62 OCCASIONAL COMPLICATIONS OF THE DISEASE. 
 
 in fact, is found to be the case in regard to the rheumatic poi- 
 son. The joints and the surrounding structures are the parts 
 most commonly implicated ; but not unfrequentlj the pericar- 
 dium and endocardium, the investing and lining membranes of 
 the heart, become the seat of rheumatic inflammation, and, in 
 some rare cases, the heart itself does not escape entirely un- 
 scathed.* The uterus, the kidneys,^ and more rarely the liver, 
 sometimes experience the effect of its irritation, and the lungs are 
 not unfrequently affected, as is evidenced by the supervention of 
 bronchitis and pneumonia.^ In some cases active pleurisy 
 supervenes, and more rarely inflammation of the sac of the 
 peritoneum.* The eyes occasionally suffer, as do also the 
 testes, the skin,^ the muscles,*' and the periosteum in various 
 
 ' For cases of rheumatic inflammation and suppuration of the heart, see 
 " Medical Gazette,"'Vol. iii, p. 118 ; a Note to Mason Good's " Study of Med- 
 icine," vol. ii, p. 153; Dr. Watson's " Lectures," ed. 1, vol. ii, p. 287; and 
 " Trans, of the Pathological Society." vol. ii. 
 
 * For a remarkable case in point, see Case in, Cap. vii, of this Treatise. 1 
 have also seen nine cases in which the urine has become albuminous, for a 
 few days, during the course of acute rheumatism, and two in which I detected 
 blood globules by the microscope. The most remarkable case in point, how- 
 ever, is one which occurred in University College Hospital, under the care of 
 Dr. A. T. Thompson, and which has been recorded by Dr. John Tajlor, 
 (" Med.-Chir. Trans.," vol. xxviii.) " The urine was not albuminous on the 
 patient's admission, but in a short time it became so highlj' charged with this 
 principle as to assume a solid form on being heated, and its specific gravity at 
 th'; same time mounted to lOfjO. After a few days more no trace of albumen 
 remained, and the urine had assumed its ordinary appearance and density." 
 
 * For cases in point, see Cap. X of this work. Latham's " Clinical Med- 
 icine," p. 161. A Paper by Dr. Wells, in the "Transactions of a Society," &c., 
 vol. iii, p. 406. A Paper by Dr. John Taylor, " Med.-Chir. Trans.," vol. xxviii, 
 pp. 511—13. 
 
 * For cases in illustration, see Case ii. Cap. vii, of this Treati=e ; as also 
 " Andral's Clinique," p. 535, and " Med.-Chir. Trans.," vol. xxviii, p. 5 12. 
 
 * Several remarkable instances in point have come under my care in St. 
 George's Hospital, in which the extremities, upper as well as lower, have been 
 covered with a patchy erythematous eruption, resembling erythema nodosum. 
 The same observation has been made by others. Thus my colleague. Dr. Wil- 
 son, says — "During the present summer of 1844, two lads, aged 15, fell under 
 my care at St George's Hospital, in both of whom a red patchy (cutaneous) 
 eruption was associated with the arthritic symptoms of ill-developed rheumatic 
 fever." (Dr. Wilson on the "True Character of Acute Rheumatism." "Lan- 
 cet," 1844, vol. ii, p. 194.) 
 
 6 See Notes of a case in St George's Hospital, under the care of Dr. Bence 
 Jones, reported in tlic •' British Medical Journal," Jan. 10, 1857.
 
 LIABILITY OF THE WHITE FIBROUS TISSUE. 63 
 
 parts of the body. Dr. Watson has reported rheumatism of 
 the articulation of the jaw, Dr. Cophmd and others of rheu- 
 matic inflammation of the membranes of the spinal cord, and 
 instances of inflammatory afi"ection of the dura mater are to be 
 found in every work on rheumatism. And other parts are 
 secondarily, even if they be not primarily, implicated, for the 
 cartilages of the joints may inflame and ulcerate,' and even the 
 osseous structures may become involved in the mischief. That 
 such complications would occasionally arise, might have been 
 expected, a jjrioi'i, from the general distribution of the cause 
 of irritation, and the severity of the local symptoms induced ; 
 and, though many of these complications are happily of rare 
 occurrence, and are seldom, if ever, met with in otherwise 
 strong and healthy subjects, yet to deny their existence is to 
 disregard facts which are fully confirmed by experience. 
 
 But not only does the rheumatic virus obey the general law 
 of poisons, in that its action is not limited to any one texture 
 or organ of the body, it further resembles this class of agents 
 in displaying a partiality for a particular texture, and partic- 
 ular organs upon which it fixes in preference to others. Such 
 a texture is the white fibrous tissue, which enters into the 
 formation of the aponeurotic sheaths, the fasciae, the capsules 
 of the joints, the ligaments and tendons, and the fibrous-serous 
 membranes in various parts of the body. The parts, there- 
 fore, most commonly aff"ected are the joints and their sur- 
 rounding structures, the valvular apparatus of the heart, and 
 the fibrous-serous covering of the heart, the strong white glis- 
 tening sac of the pericardium." 
 
 1 See Case xvi, Cap vii, of this Treatise. 
 
 '^ Dr. Law observes that the endocardium, more especially that part of it 
 which is usually the seat of rheumatic intlammatiou, has its corresponding 
 anatomical elements in the structure of the joints ; the lining membrane of the 
 valves is analogous to the synovial membrane of the joints, and the fibrous 
 tissue which enters into their composition to the tendinous structures which 
 enter into the formation of the joints. So also the pericardium exhibits, in its 
 compound constitution, its serous lamina corresponding to the synovial mem- 
 brane, and its fibrous lamina to the fibrous elements of the joints. To the 
 mitral valve having so much more of this fibrous structure in its composition 
 than the sigmoid valves of the aorta, he would ascribe its being so mu'h more 
 frequently the seat of rheumatic inflammation than they are. (See " Dublin 
 Med. Journal," vol. xvi )
 
 64 LIABILITY OF. PARTICULAR JOINTS. 
 
 The reason of tliis predilection of the rheumatic poison for 
 the fibrous and fibro-serous textures throughout the body, is 
 not at first sight obvious, nor, indeed, after careful consid- 
 eration, can we assign to it other than a conjectural cause. 
 But it is Avorthy of note, that the textures most commonly 
 implicated in rheumatism are all oiamples of the albuminous 
 and gelatinous tissues, from the decomposition of which, in the 
 wear and tear of the body, are formed those secondary organic 
 compounds, the lithic and lactic acids, with which gout and 
 rheumatism are intimately connected. And as it is but con- 
 sistent with our knowledge respecting the processes of nutri- 
 tion and assimilation, to suppose that each tissue selects from 
 the blood, and appropriates to itself such matters as correspond 
 with it in chemical constitution, Ave may readily conceive that 
 some peculiar attraction may be exerted by the fibrous and 
 fibro-serous textures for compounds, such as the lithic and lac- 
 tic acids, to Avhich they bear so strong an affinity. 
 
 There are some curious facts in connection Avith this subject 
 which require particular notice. It has long been observed, 
 not only that the joints and the surrounding structures are 
 particularly liable to be affected by rheumatism, but that some 
 joints are more prone than others to be attacked. Those 
 joints, for instance, Avhich are most exposed, as the knees, the 
 feet and the ankles, the Avrists and the hands, are the parts 
 most commonly implicated : next in order, perhaps, folloAv the 
 elbows, and then the shoulders and the hips. The larger 
 joints suffer more frequently than the small, and the small 
 joints of the hands and fingers more commonly than those of 
 the feet. 
 
 Those joints, again, which have been the seat of local mis- 
 chief, are more than ordinarily apt to suff'er. Thus, a man 
 falls down and sprains his ankle or his knee, and after a time, 
 Avith care and attention, he entirely regains the use of the 
 part, and experiences no inconvenience from his injury. But 
 if he is afterward attacked by rheumatism, the joint which 
 had been formerly injured is almost certain to be affected, and 
 Avill be so in every subsequent attack, and in all probability it
 
 SYMMETRY OF RHEUMATIC AFFECTION. 66 
 
 will be the very part in which the earliest local symptoms are 
 manifested. 
 
 The same holds good in regard to those parts which are 
 chiefly exercised, more especially when the exercise has been 
 violent and long continued.^ Blacksmiths, for instance, who 
 wield a heavy hammer, very generally sufi'er most in the joints 
 of the arm ; washerwomen in the joints of the hands and fin- 
 gers ; gardeners, and others accustomed to digging or stoop- 
 ing, are exceedingly liable to lumbago and sciatica ; and post- 
 men, and others much employed in walking, are peculiarly 
 subject to rheumatism of the legs. In all these cases the 
 nutrition of the parts affected is unusually exalted, their 
 power of attracting and separating from the blood such mat- 
 ters as correspond with them in chemical constitution is pro- 
 portionably increased, and hence the reason of their being 
 aff"ected prior and in preference to other parts of the body.^ 
 
 Another fact to which especial attention was first directed 
 by Dr. W. Budd, of Biistol, is, that, cceteris paribus, corre- 
 sponding parts of the body are similarly aflfected. If one knee 
 is attacked, it is probable that ere the close of the disease, 
 more particularly if of long duration, the other will become 
 implicated in the mischief : if one wrist suifers, the other will 
 eventually sufi'er also. Nor is it strange, if the local afiection 
 be due to the irritative property of any matter in the blood, 
 that parts which correspond in function and organization, and 
 are equally subjected to the same cause of irritation, should 
 suffer equally and in a similar manner. It is only surprising 
 that any one should hesitate to assign a constitutional origin 
 to a disease presenting features so strongly indicative of a 
 poisoned condition of tlu; Idood. 
 
 1 Tliis fact, I believe, was first pointed out by Cruveilhier. 
 
 '^ May not tliis be tlie true explanation of the fact, that the pericardium and 
 endocardium suffer more frequently than do the fibro-scrous membranes in 
 other parts of the body? The dura mater, for instance, firm in its attach- 
 ments to an unyielding structure, is not exposed to any special cause of 
 excitation, whereas the heart is necessarily in a state of great excitement, its 
 investing and lining membranes are consequently subjected to increased ten- 
 sion and increased friction, their nutrition is proportionably exalted, and 
 everything therefore is in a state to favor the irritative action of the rheumatic 
 poison.
 
 66 CLASSIFICATION OF RHEUMATISM. 
 
 Whatever the part of the body attacked, the aspect of rheuma- 
 tism varies greatly in different cases. Sometimes the disease is 
 acute ; sometimes mild, both in its local and constitutional 
 symptoms; at one time some part of the body is affected, 
 which at another, perhaps, remains unaffected throughout. 
 Hence has arisen the division of rheumatism into several dif- 
 ferent varieties. Strictly speaking, an}'^ division must be neces- 
 sarily incorrect, inasmuch as, however varying in the locality 
 and intensity of their symptoms, all forms of the disease may 
 and do constantly pass the one into the other, and nothing 
 has been hitherto ascertained as to their pathology to justify 
 such a separation. But, doubtless, pathological differences do 
 exist, though they have as yet eluded our research, and prac- 
 tically there is much advantage in adopting some artificial 
 arrangement. Not only do the different vai-ieties occur under 
 different circumstances of age, sex, constitution, and the like, 
 but they require treatment differing widely in its character. 
 Hence it becomes expedient to make such practical distinctions 
 as are calculated from their simplicity to facilitate the descrip- 
 tion of the various modifications of the disease ; and those 
 which I propose to adopt are, 1st, acute rheumatism, or rheu- 
 matic fever ;^ 2d, rheumatic gout ;^ 3d, chronic rheumatism; 
 4th, neuralgic rheumatism. 
 
 Acute rheumatism, as its name imports, is characterized by 
 
 ' Some persons cavil at the term acute rheumatism, and urge the invariable 
 adoption of the term rheumatic fever, as pointing to the constitutional char- 
 acter of the disorder. But the fever which accompanies acute rheumatism is 
 one only out of many remarkable symptoms which characterize a well-marked 
 attack of the disease : moreover, the term " fever' is more or less applicable to 
 all the modifications of the disease, inasmuch as some functional dif turbnnce 
 exists even in the mildest cases. Therefore, unless the term "rheumatic fever" 
 be applied indiscriminately to all forms of the complaint, which would lead to 
 endless confusion, it appears to me better to adopt a nomenclature which docs 
 not involve a question of origin, rather than by any title to impute a functional 
 character to one form of the disease and by inference deny it to another. 
 
 2 By Dr Macleod, these cases were classed with true rheumatism, under the 
 title of synovial rheumatism ; but I believe they will be found to have a special 
 pathology, and to be totally distinct from rheumatism and gout. I therefore 
 propose to consider them under the common and significant title of Rheumatic 
 Gout.
 
 CHARACTERISTICS OF ACUTE RHEUMATISM. 67 
 
 symptoms of active disease. It is generally ushered in by a 
 smart attack of fever, accompanied by a quick bounding pulse, 
 a foul tongue, loaded urine, profuse, acid, sour-smelling per- . 
 spiration, and wandering pains in the limbs. After a period 
 of varying duration, the pains fix on one or more of the larger 
 joints, which become hot, red, and swollen, and exquisitely 
 tender on pressure. Unlike inflammation arising from truly 
 local causes, this rheumatic inflammation shifts repeatedly, 
 and oftentimes rapidly, from joint to joint, displaying in each 
 great apparent intensity, yet rarely producing permanent mis- 
 chief, so that the joint which to-day seems to threaten suppu- 
 ration, may to-morrow evince no mark of the violent invasion 
 it has undergone. Sometimes the swelling extends a consid- 
 erable distance from the- joint itself, and is evidently chiefly 
 external to the articulation, for there is a puflSness about the 
 parts aff"ected, and the hollows and depressions in the vicinity 
 of the joints are filled up by effusion into the cellular tissue. 
 At others, the inflammation is less superficial ; there is less 
 redness, and the swelling, which is more defined and limited 
 in extent, is evidently due in great measure to inflammation of 
 the synovial membrane with eff"usion of fluid within the joint, 
 for the distended capsule projects at those parts where the 
 surrounding tissues offer least resistance. In most instances 
 the two varieties of swelling are intimately blended, the diff"use 
 fibrous symptoms predominating at one period of the disease, 
 the synovial symptoms at another ; but in proportion as the 
 synovial symptoms become more prominent, and the diff"use 
 fibrous symptoms less marked, so does the case assume more 
 and more the character of that form of disease which I purpose 
 describing under the title of Rheumatic Gout. 
 
 From first to last the disease may run its course without the 
 implication of any internal organ ; but not unfrequently it is 
 accompanied by inflammation of the investing or the lining 
 membrane of the heart, as also by inflammation of the lunge 
 or plourte. 
 
 The second variety presents some of the characters of gout 
 more or less blended with those of rheumatism, but is, never-
 
 68 DIFFERENT VARIETIES OF RHEUMATISM. 
 
 theless, essentially distinct from the ,one and the other. It 
 seldom occurs in early life, except when there is a taint of 
 gout or rheumatism in the system ; it is not accompanied by 
 the profuse sweating of rheumatism, and does not involve the 
 heart or its membrane. The articular inflammation is some- 
 times confined to one or two joints, very generally affects the 
 smaller joints, is almost Avholly within the capsule, or the 
 bursae or sheaths of tendons in its vicinity, is much less migra- 
 tory than in true rheumatism, is marked by less extended red- 
 ness, and is accompanied by less active symptoms of fever. 
 But it is more obstinate in its continuance, more apt, when in 
 an acute state, to induce disorganization of the joints, more 
 prone, even in a less active form, to give ris^ to permanent 
 thickening and enlargement, and often to frightful and irreme- 
 diable distortion. 
 
 In chronic rheumatism, the pain is often referred to the mus- 
 cular structures, and is probably seated in the muscles them- 
 selves, their tendons, and fascioe : very little, if any, redness 
 or swelling is produced, but the affected parts are stifl" and pain- 
 ful, and the pain is aggravated by motion or pressure. Some- 
 times, however, in cachectic states of the constitution, the pain 
 is referred to those parts where the bones are thinly covered 
 by integument, as on the shafts of the long bones, on the ster- 
 num, the clavicle, and the cranium ; and if the seat of pain be 
 carefully examined, there will be found a rough irregular swell- 
 ing, tender on pressure, arising from thickening of, and effusion 
 under, the periosteum in that situation. Sometimes, again, the 
 joints are more or less affected: they are stiff and painful, and 
 present some slight and temporary tumefaction, but they are 
 not red, and are seldom tender on pressure, as are the inflamed 
 joints during an acute attack. The local symptoms are migra- 
 tory, though usually less so than in the acute form of the dis- 
 ease ; there is not much sweating, the urine is seldom loaded, 
 and the tongue is not greatly coated ; in short, there is far less 
 constitutional disturbance than in the acute form of the disease. 
 
 In the fourth species the pain is usually well defined, and 
 
 i
 
 DIFFERENT VARIETIES OF RHEUMATISM. 69 
 
 appears to follow the course of particular nerves, more espe- 
 cially those supplying the face and the inferior extremities. 
 The seat is probably the sheaths of the nerves, which are either 
 simply irritated by the rheumatic poison, or else undergo actual 
 inflammation, accompanied by effusion and consequent pressure 
 on the nerves themselves.
 
 CHAPTER IV. 
 ACUTE RHEUMATISM, OR RHEUMATIC FEVER. 
 
 One of the commonest and most severe disorders to which 
 the inhabitants of this country are liable, is that known as 
 acute rheumatism, or rheumatic fever. Formidable as well 
 from the intensity of the fever as from the agonizing pain of 
 the limbs which it occasions, it is rendered peculiarly fearful 
 and distressing by the consequences to which it frequently 
 gives rise. For the heart is often damaged by the violence of 
 its attack, and becomes inapt for the purposes of the circula- 
 tion, and when this is the case, the mischief gradually increases, 
 until it issues in palpitation, dyspnoea, and dropsy. Thus not 
 unfrequently, in the prime of life, the unhappy patient falls a 
 victim to a disease of which the seeds were sown, perhaps, 
 years before, during an invasion of articular rheumatism. 
 
 Acute rheumatism is usually met with between the ages of 
 15 and 50, few cases occurring before, and as few after that 
 period of life. It is frequently hereditary, occurs in nearly 
 equal proportion among men and women, and shows itself 
 pretty uniformly throughout the year.^ At whatever age it 
 makes its appearance it presents great diversities in its mode 
 of attack. It may commence without previous notable derange- 
 ment, either general or local : the patient may consider him- 
 self in tolerably good health, when, on exposure to cold, or to 
 some less obvious exciting cause, he is suddenly seized with 
 aching pain and stiffness in the'limbs. This gradually increases 
 in severity, and in the course of a few hours, sometimes within 
 a shorter period, is accompanied by redness and swelling, and 
 tenderness of the joints, as also by symptoms of constitutional 
 disturbance. 
 
 1 For statistics and full particulars on these subjects, see Cap. II of this 
 Treatise, pp. 56-60.
 
 ACUTE RHEUMATISiM. 71 
 
 In another case the attack may be ushered in bj febrile 
 excitement, marked bv all the characteristic features of rheu- 
 matic fever, yet unaccompanied by pain or the slightest artic- 
 ular redness or swelling, and sometimes the disease may even 
 run its course unattended by pain or local inflammation. More 
 commonly, however, after a certain period, pain and inflamma- 
 tion make their appearance. In most instances the joints and 
 the surrounding structures are the parts which first give evi- 
 dence of irritation, but in some few cases, the heart or its mem- 
 branes are affected for some time prior to the setting up of 
 articular mischief.^ 
 
 In another, and by far the largest, class of cases, the patient 
 presents symptoms of functional derangement long before the 
 full development of the disease. Though not actually feverish, 
 he is evidently "out of sorts;" he feels chilly, languid, and 
 uncomfortable ; is unusually sensitive to atmospheric vicissi- 
 tudes, and from time to time experiences pain, or threatening 
 of pain, in the limbs. His friends probably observe that his 
 temper is irritable, his appetite capricious, and that he is 
 unwilling to exert himself as much as usual, and if pressed to 
 give an opinion on the subject, they will say he looks pale and 
 far from Avell. The complexion is sallow and unhealthy, the 
 eyes are dull, and the conjunctivae yellowish. The pulse, per- 
 haps, is hardly above the natural standard, but the tongue is 
 white or coated, he has a sour disagreeable taste in the mouth, 
 the urine is high colored and often turbid, and the bowels are 
 irregular or sluggish in their action. 
 
 This is the preliminary sickening for the attack. Up to 
 this point the patient feels so little indisposed that he seldom 
 has recourse to medical advice. He fancies "he has caught 
 cold," and comforts himself with the idea that "it will soon 
 pass off." But the pains in the limbs become more constant 
 and severe ; he finds it difficult to move, as every attemjit at 
 motion aggravates his suffering ; and thus he goes on, until he 
 is chilled by sitting in a draught, by getting his feet wet, by 
 sleeping in damp sheets, or by some similar circumstance, 
 
 • See Cap. VI of this Treatise, Note on p. 138.
 
 72 GENERAL SYMPTOMS OF 
 
 when a fit of shivering occurs, unequivocal febrile symptoms 
 declare themselves, articular inflammation commences, and he 
 is obliged to take to his bed. Then he discovers the folly of 
 neglecting the advice of Ovid, who says : 
 
 " Principiis obsta ; sero medicina paratur 
 Cum mala per longas invaluere moras — " 
 
 "VMien once a paroxysm is fully established, the patient pre- 
 sents a pitiable spectacle of helpless suflfering. He is exceed- 
 ingly restless, yet lies motionless on his back, unable to stir, 
 afraid to allow himself to be moved by his attendants, and in 
 constant dread, when they approach his bed, lest, by some 
 accidental pressure, they should aggravate his already agoniz- 
 ing pain. Even the weight of the bedclothes is too much for 
 him, and he generally asks to be relieved from their pressure. 
 His expression portrays the suffering he is enduring, and indi- 
 cates, at first sight, the severity of the disease. Yet his aspect 
 differs very remarkably from that of a person laboring under 
 continued fever. It is not so dull, heavy, and depressed ; 
 neither is there the same flushing and suffusion of the face ; 
 nor the like dry burning heat of skin. Indeed, the counte- 
 nance is seldom much depressed, the face is usually pale and 
 sallow, and though the skin is sometimes hot and dry, it is 
 more commonly bathed in profuse acid perspiration, which 
 stands in large drops upon the chest and forehead, and emits 
 a peculiar, sour, disagreeable odor, eminently characteristic of 
 acute rheumatism. The tongue is moist, but coated with a 
 deep-white or yellowish-white fur, and the saliva, which in 
 health is alkaline or neutral, becomes decidedly acid. The 
 bowels are generally costive, and when acted on by medicine, 
 •the evacuations are dark colored and offensive. The urine is 
 scanty, dark colored, and of high specific gravity, extremely 
 acid, and loaded with lithates, which are deposited as a 
 copious, red, brickdust sediment.' The pulse is accelerated, 
 
 ' At the outset of the disease, the high specific gravity of the urine is due 
 to a relative, rather than to a positive, increase in the quantity of the matters 
 excreted by the kidneys. The solid constituents of the urine are not in excess, 
 but the quantity of water is far below the average. In two cases I have found
 
 ACUTE RHEUMATISM. 73 
 
 varying in frequency from about 90 to 130 in a minute, and is 
 full and bounding to a degree seldom observed in any other 
 disorder. The appetite varies ; it is generally impaired, but 
 occasionally almost as good as usual ; and thirst, though some- 
 times excessive, is not usually an urgent symptom. From first 
 to last, if the case be not complicated by some internal affec- 
 tion, the head usually remains clear, the intellect unobscured ; 
 there is no headache, no delirium, neither is there subsultus 
 tendinum, nor other evidence of the disturbance of the nervous 
 centers which is commonly met with in continued fever. But 
 the pain precludes the possibility of sleep ; and, before the 
 disease has run its course, the patient is exhausted and 
 becomes irritable and fractious. 
 
 The local symptoms of the disease are equally striking and 
 peculiar. At first they consist of little more than pains wan- 
 dering capriciously from limb to limb, and producing more or 
 less temporary stiffness. But when the attack is more fully 
 established, the pains, though shifting from one spot to an- 
 other, until few parts of the body have been left free from in- 
 vasion, fix more particularly upon the larger joints.^ These 
 rapidly pass into a state of inflammation, and become hot, red, 
 and painful, as also tender to the touch. After the lapse of a 
 few hours, effusion takes place into the adjacent cellular tissue ; 
 the hollows and depressions about the joints are obliterated ; 
 
 the urine abundant, pale, alkaline, and turbid, containing crystals of the 
 ammonio-magnesian phosphate. In both .instances, the patients were weakly, 
 and their perspiration was of a peculiarly acid nature. Something of the 
 same sort has been remarked by others. (See Simon's " Chemistry-," vol. ii, p. 
 275.) Occasionally, when there is much renal irritation, the urine is slightly 
 albuminous, coagulating by heat and nitric acid, and a few blood corpuscles 
 may then be discovered in it by the aid of the microscope ; but usually, a few 
 scales of epithelium, together with an amorphous deposit of lithates, and here 
 and there a few crystals of lithic acid, or of oxalate of lime, are alone observed 
 on a microscopic examination. Minute crystals of lithic acid are also found 
 sometimes in the pellicle which forms on the surface of the urine. 
 
 ^ Other parts of the body besides the joints are liable to become the seat of 
 pain in acute rheumatism. Such, for instance, are the loins, the neck, the 
 scalp, and the parietes of the chest and abdomen. Affection of these parts, 
 however, is not so common in the acute as in the more chronic form of 
 the complaint ; and I shall therefore defer entering upon their consideration 
 until I speak of Chronic Rheumatism. 
 6
 
 74 LOCAL SYMPTOMS OF 
 
 and the surrounding skin, which had been hitherto moist and 
 perspiring, becomes dry, tense, and shining ; so much so, 
 indeed, that experience alone enables us to predict that sup- 
 puration will not take place. 
 
 Sometimes, however, the parts present a somewhat different 
 aspect. The articular swelling is more circumscribed, and in 
 its form and character indicates the existence of effusion within 
 the joint rather than into the surrounding tissues. There is 
 less superficial redness and swelling, but there is evident full- 
 ness and distention of the synovial membrane, which bulges at 
 those parts where the surrounding tissues offer least resistance, 
 forming a swelling in which fluctuation is perceptible. These 
 two varieties of swelling are usually more or less intimately 
 blended, the synovial symptoms predominating at one period 
 of the disease, the diffuse fibrous symptoms at another. But 
 in proportion as the latter are absent and the former are more 
 strongly marked, so does the case lose the characteristics of 
 true rheumatism, and assume those of the disorder which I 
 purpose describing under the title of Rheumatic Gout. 
 
 A remarkable feature of the articular inflammation, is its 
 migratory nature. In the course of a few days, nay, some- 
 times within a few hours, the enemy begins to shift his quar- 
 ters, and joint after joint undergoes in turn the infliction of 
 his terrible visitation. The knee, which to-day is red and 
 swollen, may to-morrow present no trace of mischief, while 
 the wrists, the elbows, the ankles, or the knuckles, which have 
 been hitherto free from pain, may in a few hours become the 
 seat of inflammation. Moreover, after evacuating its first 
 position and invading several joints successively, inflammation 
 not unfrequently recommences in its old quarters, and the 
 parts go through the same series of changes to which they had 
 been previously subjected. In some instances, however, the 
 parts first affected remain so throughout the attack ; and it 
 will be observed, that the obstinacy and fixity of the inflam- 
 mation very generally vary in an inverse proportion to the 
 number of the joints implicated. 
 
 The subsidence of inflammatory action at one part, and its
 
 ACUTE RHEUMATISM. 75 
 
 commencement at another part of the body, appear sometimes 
 to be simultaneous actions, but more commonly the mutual de- 
 pendence of these phenomena is by no means clearly marked. 
 A fresh joint may be, and constantly is, attacked without any 
 decrease in the activity of the inflammation observed in the 
 parts primarily affected, and even when a diminution of action 
 is perceptible, it usually occurs slowly and imperfectly, and the 
 parts first attacked remain for some days tumid, painful, and 
 tender. So that, in many cases at least, the fresh inflamma- 
 tion set up is obviously a mere extension of the disease. 
 
 Rheumatic inflammation, whatever its character and appar- 
 ent intensity, very generally subsides, without the superven- 
 tion of the ordinary ill effects of inflammatory action.^ Some- 
 times, indeed, as I shall presently point out, the joints do go 
 on to suppuration ; but more commonly the redness and 
 swelling disappear, the skin again becomes flaccid, and gradu- 
 ally resumes its perspiratory function; and thus throughout 
 the whole course of the disease, a series of local changes is 
 kept up, which seldom leave any permament ill effects, though 
 varying greatly in the rapidity of their occurrence, at one time 
 occupying a few hours only, and at another several days, in 
 their completion. 
 
 A considerable increase in the severity of the pain and some 
 exacerbation of the febrile symptoms, is usually observed to- 
 wards evening, while, as morning advances, the unhappy pa- 
 tient again experiences some remission of his sufferings. These 
 curious alternations have been attributed by some to mere vari- 
 ations in the external temperature; and the oft-cited fact that 
 the pains of rheumatism are sometimes aggravated by heat has 
 been confidently appealed to in support of this doctrine.^ But 
 
 ' I here allude only to the articular inflammation, for when the heart, the 
 lungs, or the pleurae are attacked, the ordinary products of inflammatory 
 action are almost invariably produced. 
 
 * That heat does occasionally aggravate rheumatic pains, is a fact which 
 does not admit of doubt, but it does so most strikingly, when it fails to pro- 
 duce free cutaneous action. I have constantly observed, that those who have 
 complained most of the increase of pain induced by warmth, are loudest in 
 their praises of the benefit accruing from profuse acid perspirations.
 
 76 PECULIARITIES OF ACUTE RHEUMATISM. 
 
 it matters not at what temperature the air of the room be kept, 
 nor whether the heat be increased or decreased, as it always 
 may be by artificial means, the periodical exacerbation in the 
 severity of the symptoms is still observed, and cannot be pre- 
 vented; and the most rational interpretation of this peculiarity, 
 which obtains even in diseases which are benefited by warmth, 
 is that probably which ascribes it to some obscure influence 
 connected with the diurnal revolution. 
 
 One of the most remarkable and suggestive facts in regard 
 to rheumatism is, that the fever and constitutional distress are 
 not necessarily commensurate with the extent and intensity of 
 the local symptoms. Not only is rheumatic inflammation of 
 the joints very frequently preceded by febrile disturbance, but 
 sometimes the fever runs so high before any local symptoms 
 have been established, as to cause even careful and intelligent 
 practitioners to mistake the nature of the impending attack. 
 Moreover, when febrile symptoms do thus precede the estab- 
 lishment of local inflammation, they are not only not increased 
 by its occurrence, but, as was remarked by the sagacious and 
 observant Sydenham,^ they are generally relieved, the pulse 
 becoming calmer, the countenance less anxious, and the patient 
 altogether easier. 
 
 Another point to be observed is, that the pain is not pro- 
 portioned to the redness and swelling, or, in other words, to 
 the apparent intensity of the local inflammation. The pain 
 may be most severe, and, indeed, generally is so, just before 
 the redness and swelling commence, and, occasionally, subsides 
 in some measure when these external evidences of inflammation 
 present themselves. Moreover, it is usually less severe when 
 much efi"usion takes place into the surrounding tissues, giving 
 rise to a certain extent of oedema, than when the parts are only 
 slightly swollen, but are exceedingly hot, with the adjacent 
 skin of a dusky, lurid red color. This I believe to be due to 
 the fact, that in one set of cases the superficial parts are chiefly 
 affected, in the other the ligaments and more deeply-seated 
 structures, which are dense and unyielding in their nature. 
 * Sydenham, " Opera," sect, vi, cap. v.
 
 PERSPIRATION BENEFICIAL IN ACUTE RHEUMATISM. 77 
 
 The former cases are accompanied by pain of a burning and 
 pricking character : the latter by a sense of gnawing or tearing. 
 In the first-named instances the local symptoms are more mi- 
 gratory, and shift their position more rapidly and more com- 
 pletely than in those last mentioned, in which, for some days 
 after all swelling has subsided, there still remains considerable 
 stijBTness about the parts, the result probably of thickening in 
 the sheaths of tendons, and in the various tissues connected 
 with the joint. 
 
 The profuse perspiration, characteristic of acute rheumatism, 
 is commonly spoken of as "wasting and enfeebling," and is 
 said to distress and weaken the patient without alleviating his 
 suffering or shortening its duration. This opinion, however, is 
 erroneous, and a mistake of some practical importance. True, 
 the perspiration is often excessive, generally disagreeable, 
 sometimes even distressing to the patient, and fails in affording 
 immediate relief. But if it be checked for a time, if the outlet 
 by which such enormous acid secretions are making their es- 
 cape be closed, it will require no very accurate observation to 
 mark the consequent increase in the severity of the symptoms. 
 The pains rapidly become worse, the constitutional disturbance 
 more striking than before, and the sufferer himself will soon 
 observe that he is easier and less oppressed when the skin is 
 perspiring than when it is perfectly hot and dry. Some cases 
 there are which, for a time at least, are unaccompanied by the 
 characteristic sweats, and in these the pains are always exces- 
 sive, and the constitutional symptoms most severe ; nor is any 
 relief obtained until, by the use of proper means, the skin's 
 action is established and perspiration commences. The mate- 
 ries morbi is in great measure got rid of, and the natural cure 
 of the disease effected by means of these profuse, sour-smelling 
 perspirations ; and unless they be replaced, as they sometimes 
 are, by diarrhoia, diuresis, or extremely acid vomiting, every- 
 thing which tends to check them tends also to protract the 
 disease. In the wards of St. George's Hospital I have had 
 repeated opportunities of noting this fact, and have frequently 
 begged the pupils to observe, that the cases of rheumatic fever
 
 78 PEKSPIRATION BENEFICIAL IN ACUTE RHEUMATISM. 
 
 which have progressed most favorably, which, though severe 
 in their local and general symptoms, have run their course in 
 a fortnight or three weeks, and have left the patient free from 
 pain, have been those accompanied by profuse acid perspira- 
 tions; while those which, in spite of medical treatment, have 
 lingered on for a period of six or eight weeks, have been those 
 in which the sweating has been less strongly acid, less perfect 
 in its development, or less constant in its continuance, taking 
 place over a portion only of the body, or occurring profusely 
 perhaps for two or three days, and then subsiding or altogether 
 disappearing. Indeed, such cases have usually continued until 
 the great accumulation of the poison in the blood, with the 
 consequent increase in the severity of the symptoms, both 
 general and local, have seemed once again to stimulate an at- 
 tempt at this system of relief. But I would not be misunder- 
 stood on this subject. Though the characteristic acid, sour- 
 smelling perspirations, which occur in the natural course of 
 the disease, are unquestionably highly beneficial to the patient, 
 as is shown by the increased severity of the symptoms which 
 results whenever they are forcibly arrested, those certainly are 
 not so which are met with in debilitated or cachectic states of 
 constitution ; which occur after the incautious use of the vapor 
 bath, or depletion carried to an unwarrantable extent; or which 
 again are sometimes witnessed toward the close of protracted 
 cases. Such perspirations are useless, wasting, and enfee- 
 bling : though almost as profuse, they emit but little of the 
 characteristic odor; they may be somewhat acid, but not highly 
 so as before ; they are not attended by the same heat of skin, 
 by the same full and bounding pulse, nor by an equally loaded 
 state of urine, but, on the contrary, are accompanied by a sod- 
 dened state of skin, by a soft, weak, irritable pulse, and not 
 unfrequently by an eruption of sudamina. The former are 
 essential to the safety of the patient ; the latter are, in great 
 measure, the effect of debility, are enfeebling and pernicious in 
 their continuance, and can and ought to be arrested. This 
 distinction may be easily verified by careful observation, and 
 it is the more important, because any misunderstanding on the
 
 SUBSIDENCE OF THE DISEASE. 79 
 
 subject might lead to an erroneous system of treatment; to the 
 forcible repression of perspiration, on the one hand, or to its 
 inordinate promotion, on the other. 
 
 When the disease begins to subside, there is generally a 
 marked change in the character of the symptoms ; the pain 
 becomes less constant and less intense, the redness and swell- 
 ing gradually disappear, the frequency of the pulse subsides, 
 the tongue begins to clean, the evacuations from the bowels 
 become less fetid and less dark colored, the perspiration less 
 profuse and less sour-smelling than before, and the urine more 
 abundant and less loaded with lithates. Many of these changes, 
 however, are not observed until the disease is obviously on the 
 decline ; and, perhaps, the only means by which it is possible 
 to anticipate a speedy subsidence of the symptoms, is by 
 noticing the condition of the tongue and urine. The former, 
 when the disease is about to yield, begins to clean, and becomes 
 less red at the tip and edges, while the latter drops its sedi- 
 ment, becomes more abundant, and contains a larger quantity 
 of salts, so that it retains its high specific gravity, notwith- 
 standing the increase in the amount of water. Under the 
 microscope, however, no difference can be detected in the 
 urinary deposits at the various stages of the complaint. 
 
 After a well-developed paroxysm of the disease uncompli- 
 cated by any internal affection, recovery is usually complete, 
 and the patient soon regains his former vigor. But in cases 
 in which the symptoms are ill developed, or which occur in 
 strongly predisposed persons, or in cachectic states of system, 
 a subacute or chronic form of rheumatism is apt to succeed the 
 more active symptoms of the disease. Either the materies 
 morbi is not fully got rid of, or the function of assimilation 
 being still imperfect, fresh poison is generated, de novo, in 
 the system. Pains consequently occur, which wander from 
 one part to another, and occasionally are attended by some 
 amount of articular swelling. In most instances these pains 
 gradually subside, and with them the tendency to swelling of 
 the joints ; but in others they continue for several weeks, and 
 do not ultimately disappear until an acute paroxysm of the
 
 80 OPINIONS RESPECTING THE 
 
 disease has been re-established, and the poison through its 
 means thoroughly eliminated. 
 
 Sometimes, after all febrile and inflammatory symptoms 
 have passed away, there remains a tenderness and aching of 
 the joints which, during the attack, have been the seat of in- 
 flammation. This must not be mistaken for the subacute or 
 chronic form of the disease just alluded to, as it is, doubtless, 
 referable not to any persistent cause of irritation, but to the 
 morbid condition in which the parts have been left. The liga- 
 ments, tendons, fascioe, and aponeurotic sheaths have not re- 
 covered their normal condition ; they are thickened and less 
 elastic than they ought to be, and the bursse are distended by 
 an unnaturally thick fluid, and thus the parts are rendered 
 stiff and inapt for motion. In acute fibrous rheumatism this 
 is less frequently the case than in that form of the disease 
 which sometimes has been called synovial rheumatism, but 
 which I purpose describing under the title of Rheumatic Gout. 
 When it does occur, it may be distinguished from chronic rheu- 
 matism, by the dull aching nature of the pain itself, by the 
 absence of pain when the parts are at rest, by the freedom from 
 pain in other parts of the body, and by there being no evidence 
 of constitutional derangement. 
 
 The duration of an ordinary uncomplicated attack of acute 
 rheumatism, has been variously stated by different writers. 
 Dr. Warren reported six weeks as its ordinary duration ; Sir 
 Charles Scudamore stated that "in a case of which the issue is 
 favorable, the fever and pains are brought to a close at the 
 end of the third week, and in slighter attacks at an earlier 
 period ; but that when the course of the disease is untoward, a 
 period of two months scarcely serves to exhaust its power of 
 producing even acute symptoms."* M. Chomel's experience 
 led him to believe that four weeks is about the average period 
 for arriving at convalescence, and that recovery never takes 
 place before the twentieth day ;- and Dr. Macleod imagined 
 
 ' On Rheumatism, p. 2"). 
 
 - " Le rheumatisme articulaire aigu quelque soit la medication employee ne 
 se termine jamais avant le vingtieme jour." (" La Lancette Franijaise," August, 
 1834.)
 
 DURATION OF ACUTE RHEUMATISM. 81 
 
 that, "with the common methods of treatment, probably five 
 or six weeks may be about its average duration."^ 
 
 My own observation has led me to believe that, even when 
 unattended by any internal affection, the disease, under ordi- 
 nary methods of treatment, endures very generally from four 
 to five weeks, and under unfavorable circumstances may be 
 indefinitely protracted. Of the 246 cases admitted into St. 
 George's Hospital, under the care of the physicians, during 
 the time I held the office of medical registrar, the great major- 
 ity were decidedly convalescent about the end of the fourth or 
 the beginning of the fifth week from the commencement of the 
 attack, and were ready to leave the hospital about the end of 
 the sixth week.^ And of 23 other cases, part of which I noted 
 in the Hotel Dieu, at Paris, and part at Addenbrooke's Hos- 
 pital, at Cambridge, considerably above one-half were of about 
 the same duration. Experience, however, has taught me to 
 believe that remedial agents are capable of still further short- 
 ening its duration ; and to such an extent does this hold good, 
 that, as I hope to show, the average duration of an uncompli- 
 cated attack may be reduced, by judicious treatment, from a 
 month or five weeks, to ten days or a fortnight. This, too, is 
 the conclusion arrived at by Dr. Garrod, who, since the publi- 
 cation of the first edition of this work, in 1852, has in great 
 measure adopted the same principle of treatment as was therein 
 recommended.^ 
 
 But the question arises as to whether acute rheumatism may 
 not be immediately arrested by treatment. Dr. Macleod and 
 many other practitioners have maintained, not only that the 
 paroxysm may be shortened, but that it may be cut short, if 
 treated vigorously at first. My evidence, however, if given 
 relative to the methods of treatment hitherto pursued, must be 
 in opposition to this pleasant theory. While I was following 
 the practice of Messrs. Chomel and Rostan, at the Hotel Dieu, 
 at Paris, I paid great attention to all the cases of rheumatic 
 
 1 On Rheumatism, p. 25. 
 
 2 See Table, appended to this Chapter, p. 84. 
 
 3 See Med.-Chir. Trans., vol. xxxviii, p. 148.
 
 82 OPINIONS RESPECTING THE 
 
 fever ; I have watched with equal care the cases admitted into 
 the wards of St. George's Hospital during the greater part of 
 the last ten years ; and in my own practice at the hospital and 
 in private life, have tested the diflferent modes of treatment 
 under which this favorable result is said to have been obtained ; 
 but it has not been my lot to witness the results ascribed by 
 different gentlemen, each to his own particular remedies. 
 Doubtless, instances are occasionally met with in which the 
 disease subsides rapidly under treatment, but such examples 
 are rare, and in my observation have occurred indiflferently 
 under all remedies. The favorable result is referable probably 
 to some change induced in the functions of assimilation, by 
 agencies altogether beyond our ken, and with ordinary treat- 
 ment it occurs so seldom, that it cannot be fairly cited as indi- 
 cating the possession of a power to arrest the disease. 
 
 With regard to the great majority of such cases, another 
 very simple and obvious explanation is applicable, namely, 
 that the duration of the disease is reckoned from the first com- 
 mencement of the treatment, and not from the actual beginning 
 of the attack. I have seen several patients recover within four 
 or five days after admission into the hospital, but in three cases 
 only, under the usual methods of treatment, have the symptoms 
 been thoroughly subdued \nthin fourteen days from the com- 
 mencement of the attack. In almost every instance of a sup- 
 posed rapid cure, investigation has shown the attack to have 
 commenced some ten days or a fortnight prior to the patient's 
 admission into the hospital, a sufficient explanation of the mar- 
 velous rapidity with which the symptoms have subsided. This, 
 however, does not hold good in regard to cases treated after 
 the plan I have recommended ; for by this method the disease 
 may be generally arrested within a week, at whatever period 
 of the attack the treatment may be commenced. 
 
 I have hitherto alluded solely to well-developed and uncom- 
 plicated cases of acute rheumatism, and the remarks already 
 made, both as to the symptoms and duration of the attack, 
 apply to such and to such alone. The disease, however, is 
 often protracted, and rendered formidable by various compli-
 
 DURATION OF ACUTE RHEUMATISM. 83 
 
 oations. One, which is observed chiefly when catarrhal affec- 
 tions are prevalent, is inflammation of the lungs or their in- 
 vesting membrane, excited no doubt by the same cause of 
 irritation as gives rise to the articular symptoms, but arising 
 at one season more than at another, in consequence of the 
 poison being determined to the lungs by the prevalence of an 
 epidemic influence. Case after case of acute rheumatism has 
 been admitted into St. George's Hospital complicated by this 
 most alarming affection, and among 136 cases recorded by Dr. 
 Latham, it was met with in. no less than 24 instances. More- 
 over, in every instance in which the case issued unfavorably, 
 either pleurisy, pneumonia, or bronchitis was present.^ 
 
 Another, and sometimes a serious complication of acute 
 rheumatism, is inflammation of the eye, generally of its sclerotic 
 coat.^ The proportion of patients in whom it occurs is ex- 
 tremely small, and it seldom arises except where there has 
 been some cause of irritation to the visual organs, and where, 
 therefore, the poison of rheumatism has been specially de- 
 termined to the irritated part. In no instance have the artic- 
 ular symptoms appeared to be relieved by its occurrence, and 
 I have, therefore, been led to regard it as a mere extension of 
 the disease. 
 
 Another and most frightful complication of rheumatism, is 
 inflammation of the brain, or its investing membranes ; another 
 is active maniacal delirium, sympathetic of inflammation of the 
 heart or lungs, or of the vitiated condition of the circulating 
 fluid; and another is suppuration, or gradual disorganization 
 of the articular structures. These happily are also rare occur- 
 rences. 
 
 The most frequent, the most dangerous, and in its conse- 
 
 1 Latham's "Clinical Medicine," pp. 1G4-5. 
 
 * Since the publication of the first edition of this work, I have seen reason 
 to doubt whether inflammation of the eye is ever a consequence of true rheu- 
 matism. Indeed, the conviction has been forced upon me that, when it occurs 
 during the progress of articular inflammation, which is not of a gouty nature, 
 the coincidence is merely accidental; or else that the primary disease is 
 "gonorrhceal rheumatism," which is, doubtless, referable to a specific poison, 
 and has no connection with true rheumatism.
 
 84 
 
 COMPLICATIONS OF ACUTE RHEUMATISM. 
 
 quences the most distressing complication of acute rlieuraatism, 
 is inflammation of the heart and its membranous envelopes. 
 This merits the most anxious consideration of every one inter- 
 ested in the safety of a rheumatic patient ; and when discussing 
 the various complications of acute rheumatism, I shall enter 
 fully into its history, symptoms, and treatment. 
 
 Table 
 
 Exhibiting the Number of Cases of Acute Rheumatism admitted into St. George's 
 Ilospital, in each month of the four years ending December 31, 1848, and mark- 
 ing the average length of time they remained in the Hospital. The great majority 
 of these patients had been ill from five to ten days prior to their admission into 
 the Hosptial. 
 
 January, 
 
 February, 
 
 March, 
 
 Number of Patients. 
 
 Average length of 
 time in the Hospital. 
 
 27 
 27 
 28 
 
 Days. 
 38 
 28 
 37 
 
 April, ..... 
 May, 
 
 23 
 30 
 
 32 
 28 
 
 June, . . . 
 
 21 
 
 431 
 
 July, 
 
 August, 
 
 14 
 16 
 
 37 
 54* 
 
 September, 
 
 October, 
 
 22 
 27 
 
 31 
 32 
 
 November, ..... 
 
 28 
 
 33 
 
 December, .... 
 Total, 
 
 26 
 
 28» 
 
 289 
 
 Aver. 35 
 
 1 The average of June is rendered unusually high by the occurrence of 1 
 case of 170, and 1 of 144 days' duration. 
 
 ^ The average of August is abnormally raised by the occurrence of four 
 cases of the respective duration of 70, 84, 99, and 119 days. 
 
 3 The average of December is reduced by the occurrence of two deaths 
 within a few days of the patients' admission, and by the cure of 1 patient in 
 11 day. This patient had been ill three weeks prior to admission.
 
 CHAPTER V. 
 
 ON THE TREATMENT OF ACUTE RHEUMATISM, OR 
 RHEUMATIC FEVER. 
 
 If the contradictory nature of the treatment recommended 
 for the cure of acute rheumatism be taken as a test of its ob- 
 stinacy and intractability, it certainly is the most tedious and 
 intractable of diseases. By some "who have regarded it simply 
 in relation to its inflammatory character, it has been considered 
 amenable to ordinary antiphlogistic remedies; and bleedings, 
 large bleedings carried usque ad deliqidujn, have been recom- 
 mended by such persons as essential to its cure. By some, 
 calomel alone, or calomel in combination with opium, together 
 with active and repeated purging, have been used with the 
 view of modifying its symptoms; by others opium has been 
 almost exclusively relied upon ; while many have insisted, with 
 equal warmth, upon the benefit to be derived from the use of 
 guaiacum and stimulant diaphoretics. Some have employed 
 cinchona, some antimony; some have recommended alkalies, 
 some acids; some have given niter in large doses; others have 
 relied almost wholly upon colchicum. Each remedy has had 
 its advocates, who have founded their opinion as to its efficacy 
 upon the rapidity with which, in certain cases, the symptoms 
 of the disease have disappeared after its employment. But, 
 as when uncomplicated by cardiac affection, the disease usually 
 terminates, sooner or later, in recovery, and sometimes sub- 
 sides with marvelous rapidity under every variety of remedy, 
 it is obvious that no sound inference can be drawn as to the 
 success of any particular method of treatment, unless such 
 treatment has been adopted largely, and has been attended 
 with tolerably uniform results. And I am sure I may say, 
 without fear of contradiction, that each and every plan of
 
 86 TREATMENT OF ACUTE RHEUMATISM, 
 
 treatment which has been hitherto proposed, is regarded by 
 the profession as unsatisfactory. If in one person's hands any 
 particular remedial course has proved efficient, it has signally 
 failed in those of another ; if at one time a remedy has proved 
 efficacious, it has been found inert or injurious at another, 
 under different circumstances of age, sex, constitution, and the 
 like. Nor does this appear strange to those who consider the 
 true nature of the disorder, and the variety of circumstances 
 under which the physician may be called upon to minister to 
 his patient's relief. The bleeding, which in the young, pleth- 
 oric, and robust, may be necessary to allay excessive vascular 
 action and cause free secretion, may, in the weakly, induce 
 irritability of the heart, and a consequent attack of cardiac 
 inflammation. The opium, which in one person may prove of 
 the greatest service in promoting free perspiration and in allay- 
 ing the general irritability of the system, may, in another, 
 check the biliary and other secretions, and thus prevent the 
 elimination of the rheumatic poison. The continued use of 
 calomel and the constant purging, which may be beneficial to 
 one patient by removing large quantities of unhealthy secre- 
 tions, may unnecessarily exhaust the strength of another, and 
 tend very greatly to impede recovery. And so in regard to 
 every remedy which has been proposed. What is useful at one 
 time, proves useless or positively injurious at another; and the 
 conclusion is forced upon us, that what is wanted, "is far less 
 the discovery of untried methods of treating disease, than of 
 discriminative canons for the proper use of those we possess;" 
 far less the discovery of any new medicines, than the adapt- 
 ation of our present remedies to the exigencies of each case. 
 
 Unfortunately, until within the last few 3'ears, our surmises 
 respecting the origin of rheumatism have been confessedly in- 
 correct; our acquaintance with many of its commonest and 
 most important phenomena has been imperfect. Hence it has 
 been difficult to make choice of proper remedies, and to appor- 
 tion them rightly to the relief of the disease. Of late, however, 
 rapid progress has been made toward a full understanding of 
 the nature of the malady. Constant and diligent pathological
 
 OR RHEUMATIC FEVER. 87 
 
 research, by connecting many internal lesions witli its attack, 
 has gone far to elucidate the mystery of its birth; and close 
 induction, founded upon the observation of its phenomena 
 during life, and upon the evidence of its ravages obtained 
 after death, has served to jfiU up and illustrate the few uncer- 
 tain pages of its history. So that, from the knowledge we 
 have now acquired, we are justified in concluding, that its 
 symptoms are dependent on the presence, in the system, of a 
 matcries morbi, the product of faulty assimilation — of vicious 
 metamorphic action; that the articular inflammation, though 
 very severe, subsides, in most instances, without leaving behind 
 it any trace of its existence, and is peculiarly prone to affect 
 any part which has been or is in any way subjected to irrita- 
 tion. We have learned that, although there be excessive febrile 
 disturbance, it rarely leads to serious consequences; although 
 there be active articular inflammation, it does not usually in- 
 duce disorganization of the joints; although the disease be 
 accompanied by every symptom calculated to cause alarm for 
 the integrity of the structures, and for the continuance of the 
 functions of life, it almost invariably terminates favorably, 
 unless the heart or its membranes become inflamed. Thus 
 have we been taught to recognize and appreciate the grounds 
 on which our treatment should be based; we have been taught 
 the hopelessness of attempting to subdue the fever, or allay the 
 pain and swelling of the joints, so long as the blood is infected 
 by the poison which is at once the source and maintenance of 
 the mischief; as also the importance of neutralizing the morbific 
 element, of promoting its elimination, of taking active means 
 to prevent its further formation, and of avoiding everything 
 likely to excite or irritate the heart, and so to render it prone 
 to inflammation. 
 
 By what means, then, can we best effect our purpose, and to 
 what extent is it prudent to employ these means? 
 
 If the matcries morbi be indeed an acid, or an acidulous 
 compound ; if it be lactic acid, for instance, as there are cogent 
 reasons for believing it to be, then will its neutralization be 
 effected, its irritative property probably diminished, and its
 
 88 TREATMENT OF ACUTE RHEUMATISM, 
 
 elimination promoted by a free exhibition of alkalies and neutral 
 salts; and these objects may be further advanced by the ad- 
 ministration of purgatives, sudorifics, and diuretics, to act upon 
 the various excretions. "With the view of checking the further 
 formation of the poison, and of restoring that healthy state of 
 assimilation which, at the outset of the disease, is interrupted 
 or arrested, colchicum, mercurials, and alteratives may be 
 given, and, as the febrile symptoms begin to subside, may be 
 combined with, or followed by the use of quinia, or of some 
 other tonic, which, at certain stages of the complaint, may be 
 better calculated to improve the function of assimilation. In 
 allaying the general irritability of the system, and more par- 
 ticularly the irritability of the heart, opium, belladonna, hyos- 
 cyamus, and digitalis are remedies of the greatest value; and, 
 if vascular action be excessive, and secretion sluggish, blood- 
 letting may be sometimes employed beneficially, and antimony 
 administered in aid of other remedies. 
 
 Such is the rationale of the treatment to be adopted. When 
 the objects to be accomplished are fairly understood, the means 
 of attaining them will be obvious to every one conversant with 
 medicine ; and the question to be decided is not so much what 
 remedies should be employed, as in what quantities and under 
 what circumstances each remedy should be made use of. 
 
 Before explaining my own views on this subject, I will take 
 a brief review of the various remedies and the chief methods 
 of treatment which have been hitherto recommended for the 
 cure of rheumatism ; and first, as to the heroic remedy of vene- 
 section. In no disease is the febrile heat greater, the pulse 
 fuller or more bounding, the local inflammation apparently 
 more severe, and accompanied by more pain, than in acute 
 rheumatism; in none is the blood drawn more buffed or cupped ; 
 in none, therefore, does depletioij promise greater success. 
 Accordingly, from the time of Sydenham, free blood-letting 
 has been had recourse to more or less generally; by many as 
 an auxiliary to other treatment, by some as a substitute for 
 all other remedies. Among the most recent and strenuous 
 advocates of large and repeated bleedings, have been Mons.
 
 i 
 
 OR RHEUMATIC FEVER. 89 
 
 Bouillaud in France, and Dr. Macleod in England. These 
 gentlemen recommend the abstraction of three or four pints 
 of IMood in the course of the first few days of the attack.* 
 They endeavor thus to lessen the force of the heart and arteries, 
 and so to moderate local action ; and they assert, not only that 
 they are generally successful, but that, in many instances, they 
 have arrested or cut short the disease. 
 
 Now, without denying the accuracy of their statements, I 
 feel bound to enter an earnest protest against the mode of 
 practice they propose. In certain instances copious and 
 repeated blood-letting undoubtedly appears to mitigate, for a 
 time, the severity of the symptoms, and to render them more 
 amenable to other treatment. But if some cases recover mar- 
 velously under its influence, so do they under the use of milder 
 remedies ; if, in some instances, patients go on to recovery 
 without the recurrence of any untoward symptom, a far greater 
 number experience relapses in which the disease returns afresh, 
 with the fearful addition of inflammation of the heart; if relief 
 sometimes results from its employment, it much more frequently 
 produces little, and but temporary abatement of suff"ering. 
 Nor are these the only objections to its employment. Though 
 pain and inflammation may be the most urgent and prominent 
 symptoms of the disease, and may seem to demand venesection 
 for their relief, still as these symptoms, if left to themselves, 
 subside almost invariably without leaving any ill effects behind 
 them, Ave are bound to hesitate before adopting a plan of treat- 
 ment which cannot but affect the strength and ultimate well- 
 being of our patient. Even if a predisposition to cardiac 
 inflammation be not engendered, as I believe it to be, by copious 
 and repeated blood-letting, still convalescence is retarded, the 
 patient weakened and rendered liable to frequent relapses.^ 
 
 ' From three to six pints of blood were usually abstracted by M. Bouillaud, 
 on the first three or four days of the attack; and Dr. Macleod was in the habit 
 of taking "from twelve to twenty ounces of blood several successive times, in 
 the course of five or six days, from persons of average robustness." (On " Rheu- 
 matism," p. 32.) 
 
 2 This was so remarkably demonstrated by M. Bouillaud's cases, that the 
 doctor is forced to admit it to be necessary, " d'eviter avec le dernier soin, le 
 plus leger refroidissement." (Op. cit. p. 137.)
 
 90 TREATMENT OF ACUTE RHEUMATISM, 
 
 " Unde," says Sydenham, "non tantum gegri vires pro tempore 
 franguntur. sed si paulo fuerit natura debilior, aliis etiam morbis 
 ad annos aliquot obnoxior fere redditur." Nor is this by any 
 means a rare occurrence ; many persons have remained in a 
 weak and sickly condition for months, or even years, after 
 having undergone Mons. Bouillaud's plan of treatment by 
 bleedings repeated "coup sur coup." 
 
 But what of venesection to a smaller amount at the outset 
 of the disease ? Would not a moderate bleeding be likely to 
 modify the local action, allay the general irritability of the 
 system, and favor the action of remedies ? I confess that, 
 according to my experience, phlebotomy is much too generally 
 adopted. If it could be shown, that in the event of its being 
 omitted, some serious mischief would arise as the effect of the 
 articular inflammation, that the heart would be implicated, or 
 that some serious consequences would result from the severity 
 of the febrile disturbance, then there would be no objection to 
 the use of the lancet. But the experience of all ages has proved 
 beyond dispute, that the febrile paroxysm is usually unaccom- 
 panied by danger ; that disorganization of the joints very rarely 
 occurs, and supervenes as often when bleeding has been prac- 
 ticed as when no blood has been taken from the arm ; and recent 
 observation adduces evidence to show that inflammation of the 
 heart is not more common, if, indeed, it be not actually less 
 frequent, where other remedies are employed, than Avhen a 
 treatment is adopted in which phlebotomy has its share. Mons. 
 Bouillaud, the great advocate of copious and repeated venesec- 
 tion, acknowledges inflammation of the heart to have been the 
 rule, and not the exception in his practice : " Coincidence a 
 peu prcs constante, soit d'une endocardite, soit d'une pcricar- 
 dite, soit d'une endo-pericardite avec un violent rheumatisme 
 aigu." ^ And Dr. Macleod, who makes no mention of the fre- 
 quency of endocarditis, reports pericarditis alone in nearly one- 
 fourth of his cases. On the other hand, Dr. Corrigan, who 
 rarely had recourse to blood-letting, observed only one instance 
 of it among many cases treated by opium ; and out of one hun- 
 
 ' Op. cit. Preface, p. ii.
 
 OR RHEUMATIC FEVER. 91 
 
 dred and sixty-eight cases in my own practice, it has occurred 
 but five times after the commencement of treatment, and in 
 four, if not in all of these instances, within the first twenty-four 
 hours before the effect of treatment coukl be felt. Nay, more, 
 though 1 have treated eighty-three cases of acute rheumatism 
 during the last three years and a half, inflammation of the 
 pericardium has not been set up in any one instance while the 
 patients have been under my care, a result which I attribute 
 to the greater rapidity with which I have lately pushed the 
 remedies. 
 
 As, therefore, there is no absolute necessity for the use of 
 venesection, as it usually aff'ords only temporary relief, and 
 as by the treatment hereafter to be mentioned, the pulse may 
 be quieted, the pain allayed, and the fever and articular 
 inflammation subdued much more rapidly and certainly than 
 by the most active depletion, I would not recommend the 
 abstraction of blood as a part of ordinary practice. In some 
 instances it is required, and is highly beneficial ; but repeated 
 observation has led me to believe, that it is so only in first 
 attacks occurring in young, robust, and generally healthy per- 
 sons, particularly in those which are marked by unusual severity 
 of their symptoms, or are unaccompanied by free perspiration, 
 and by other evidences of activity in the excretions. Even in 
 such cases it should be cautiously employed, and carried to a 
 small extent only, viz., from six to twelve ounces, according to 
 the age and strength of the patient, the object being to favor 
 the action of other remedies, and promote free secretion, rather 
 than to arrest or cut short the disease.* In the recurrent dis- 
 ease, venesection, even to a moderate amount, is always unat- 
 tended by benefit, and is sometimes followed by dangerous 
 
 1 I am glad to quote, in confirmation of my opinion, the testimony of that 
 able and experienced physician, Dr. Latham. After discussing the expediency 
 of having tecourse to it, he adds : " Summarily, then, I would venture to say 
 of venesection, employed under the most favorable conditions, and in the most 
 suitable measure, that it is to be trusted, rather as preparatory and auxiliary 
 to other remedies, than for its own exclusive remedial power in acute rheuma- 
 tism. It very often renders the disease more curable by other means, but it 
 seldom cures the disease itself." ("Clinical Medicine," vol. i, p. 190.)
 
 92 TREATMENT OF ACUTE RHEUMATISM, 
 
 consequences ; in mild cases it is unnecessary, and therefore to 
 be avoided ; in the delicate or those of a weakly constitution, 
 it is clearly inadmissible ; and in the strongly predisposed, or 
 when the disease is hereditary, it utterly fsxils in modifying the 
 morbid action, is often ill borne by the system, and therefore 
 should seldom be practiced.^ 
 
 When venesection is employed in acute rheumatism, the blood 
 
 1 In confirmation of my opinion as to the general inexpediency of bleeding, 
 I am induced to quote the following practical observations : " As far as I have 
 been able to observe, the benefit of large and repeated bleedings is in most 
 cases far from clear and unquestionable. One of the worst rheumatisms which 
 I remember, immediately succeeded a most profuse bleeding of the nose, which 
 continued so long as almost to exhaust the patient, and to bring his life into 
 imminent danger. Something like this happened in a second instance." (Dr. 
 Heberden's " Commentaries," p. 401.) 
 
 " Some practitioners continue to let blood in most cases of rheumatism, 
 thinking themselves justified in their mode of practice by the sizy appearance 
 of the blood. The same principle might lead them to empty the whole san- 
 guiferous system, for every time blood-letting is repeated, the blood becomes 
 more and more dense and sizy. I have further observed, that by bleeding re- 
 :peatedly, the pains, swellings, and febrile symptoms are not orUij aggravated at 
 the time, but often protracted indefinitely ; at least, I have seen them continue 
 ■under such a mode of practice upwards of two months." (Dr. 'Willan's " Re- 
 port on the Diseases of London," p. l"iG.) 
 
 "While it was the practice to remove the general inflammation by bleeding, 
 metastasis frequently took place to the interior parts of the body, and destroyed 
 the patient. This accident in the author's practice during the last fifteen years, 
 has rarely happened. In this period, he has entirelj- loft off l)leeding in acute 
 rheumatism, and has not lost above two or three patients, although he has 
 treated several hundred in this disease." (Third Dissertation on " Fever," p. 
 18, by Dr. Fordyce, formerly Physician to St. Thomas's Hospital.) 
 
 Dr. Alison " has no difficulty iu stating his conviction, that large and re- 
 peated bleedings, in the beginning of rheumatism, increase the risk of metastasis 
 to the heart," and " that acute rheumatism cannot probably be much shortened 
 in its duration by antiphlogistic remedies." ('' Cyclopjfdia of -Medicine," article 
 *• History of Medicine," p. !».">.) 
 
 ♦' Excessive bleeding, which has been another error in the treatment of acute 
 irheumatism, may likewise protract the disorder." (Dr. Francis Hawkins's 
 "Gulstonian Lectures.") 
 
 " It rarely happens, however, from the age of the patient, or the extreme 
 severity of the disease, that venesection is to be had recourse to more than 
 ■once." (Dr. Seymour's ""Lectures," " Med.-Chir. Review," vol. xxxiii.) 
 
 " On the whole, I would conclude that large and repeated bleedings should 
 ■be avoided in rheumatic fever." (Dr. Todd, on "Rheumatism," p. 208.) 
 
 "Although I am in the almost daily habit of treating this disease, I rarely 
 prescribe phlebotomy." (Dr. Watson's •' Lectures," ed. 1, vol. ii, p. 025.)
 
 OR RHEUMATIC FEVER. 
 
 93 
 
 drawn is remarkably buffed and cupped, and the patient will 
 bear to lose a large quantity Avithout fainting. But neither of 
 these facts is sufficient to justify the adoption of the remedy, 
 or to warrant its repetition. The tolerance of blood-letting is 
 attributable, without doubt, to the irritant property of the 
 rheumatic poison, and to the stimulating influence which the 
 blood acquires in consequence ; and the quantity of fibrin in 
 the blood is so increased,^ that the cupping and buffing will 
 continue to the last — will continue when depletion is no longer 
 safe, and when it has been carried to such an extent that an 
 anaemic murmur accompanies the heart's sounds, and a loud 
 bruit de diahle is audible in the large veins of the neck. 
 
 In conclusion, then, without denying the occasional efficacy 
 of venesection in acute rheumatism, I seldom, very seldom, 
 have recourse to its employment. Rarely, indeed, does a case 
 occur in which other and gentler means will not reduce the 
 force and frequency of the circulation, promote free secretion, 
 and allay the fever and local inflammation as rapidly as the 
 most copious blood-letting ; and whether owing to peculiar 
 bodily idiosyncrasies, or to other causes equally beyond our 
 ken, the favorable results of venesection are so rarely met 
 
 1 Messrs. Andral and Gavarret have clearlj- shown that the increase in the 
 proportion of fibrin which rises in acute rheumatism, from 2J or 3 to 8 or 9, 
 or even 10-3 parts in 1,000, is due to the existence of local inflammation, and 
 that bleeding exercises very little influence over it, unless it be accompanied 
 by a remission of the local mischief. 
 
 It exerts, however, a very manifest and constant influence over the quantity 
 of blood corpuscles, which diminish in proportion to tlie frequency of the 
 blood-letting, and the amount of blood taken. In illustration of these facts, I 
 subjoin the result of four bleedings in three cases of acute rheumatism. 
 
 
 ( Case i. 
 
 Bleeding i. 
 
 Bleeding ii. 
 
 Bleeding iii. 
 
 Bleeding iv. 
 
 G-5 
 
 G-2 
 
 7-0 
 
 6-9 
 
 Fibrin . . 
 
 " ii. 
 
 5-4 
 
 7-0 
 
 6-1 
 
 5-4* 
 
 
 ( " iii. 
 
 G-1 
 
 7-2 
 
 7-8 
 
 10-2 
 
 
 r Case i. 
 
 114-8 
 
 111-0 
 
 102-8 
 
 88-7 
 
 Globules . 
 
 " ii. 
 
 125-3 
 
 124-0 
 
 121-4 
 
 99-6 
 
 
 1 "iii. 
 
 123-1 
 
 120-7 
 
 112.8 
 
 101-0 
 
 * In case ii, the pain and inflammation were subsiding at the time of the 
 fourth bleeding. ("Annals de Chimie," vol. Ixxv, pp. 240-48.)
 
 94 TREATMENT OF ACUTE RHEUMATISM. 
 
 with, and the risk of evil consequences incurred by its employ- 
 ment is so great, that, provided as we are with remedies of 
 equal, if not of greater, efficacy, we are not justified, except 
 under the conditions already specified, in having recourse to so 
 dangerous an expedient. 
 
 In general estimation, perhaps purging stands next in 
 importance to venesection. The practice of giving large and 
 repeated doses of calomel and purgatives was first, I believe, 
 introduced by Dr. Chambers, and is certainly most powerful 
 in mitigating the severity of the disease. It allays the pain, 
 subdues the fever, and, day by day, gives abundant tokens 
 of its salutary influence. Nor can this be a matter of aston- 
 ishment to those who are familiar with the features of the com- 
 plaint. The bowels are often loaded with unhealthy, dark- 
 colored, offensive secretions : and by the practice alluded to, 
 not only are these poisonous accumulations got rid of, but the 
 stomach and intestines throughout their whole extent are stim- 
 ulated to inordinate action ; the amount of fluid excreted is 
 vastly increased, and with it a large quantity of the rheumatic 
 virus must necessarily be evacuated. 
 
 But if the advocates of this system of treatment have not 
 enlarged too much upon its value, they have at least insisted 
 too strongly upon its invariable employment. The bowels, 
 says Dr. Macleod, should be acted on by " calomel in doses of 
 from three to five grains, administered at night, and followed 
 by senna and salts in the morning. This discipline ought 
 generally to be repeated on several successive days.''^ And 
 Dr. Hope, in the same strain, recommends " calomel and opium 
 at night, and a black dose every morning, sufficient to insure 
 four or five stools at least." Now although, as above stated, 
 I admit the necessity of attending to the state of the alvine 
 secretions, and recognize free and copious evacuations by the 
 bowels as among the most powerful means we possess of allay- 
 ing the general febrile disturbance, and of promoting the elim- 
 ination of the rheumatic virus, I must, nevertheless, express 
 my dissent from the practice of repeated active purging. And 
 
 1 On "Rheumatism," p. 34.
 
 OR RHEUMATIC FEVER. 95 
 
 I do SO for three reasons. First, because it is not necessary 
 to the cure of the patient, and, like bleeding, tends greatly to 
 reduce his strength and protract recovery ; secondly, because, 
 from the nature of the complaint, the patient is quite incapable 
 of moving, and his sufferings are aggravated, his irritability is 
 increased, and his heart's action accelerated, by the repeated 
 shifting of position, -which is rendered necessary by the calls 
 of nature ; and, thirdly, because it necessarily gives rise to 
 more or less exposure, which must be prejudicial to a patient 
 bathed in perspiration. On several occasions within my own 
 experience, inflammation of the heart has supervened imme- 
 diately after the exposure, and the increase of irritability con- 
 sequent on several successive purgings, and more than once I 
 have been led to believe that this unfortunate occurrence has 
 resulted from the treatment adopted. Accordingly, our con- 
 stant endeavor should be to obtain a free evacuation every 
 morning, without the risk and great discomfort attendant upon 
 repeated purging. The remedies by which this object is best 
 obtained are — calomel combined with a full dose of opium at 
 night, and followed, when necessary, on the following morning, 
 by a draught composed of rhubarb or senna with colchicum, 
 and the potassio-tartrate of soda, in just sufficient quantity to 
 produce one full dejection. By these means, not only is an 
 abundant secretion secured from the liver and bowels,^ but by 
 waiting some hours before administering the purgative, and 
 thus giving the calomel time to do its work, we carry off the 
 excrementitious matter quite as thoroughly as by repeated 
 active purging. 
 
 There are certain cases, however, in which larger and more 
 frequent demands may be made upon the intestinal secretions. 
 It happens not unfrequently that persons attacked with acute 
 rheumatism have been constipated for some time prior to their 
 illness. Such persons present all the symptoms of biliary and 
 
 1 " The prompt and almost specific effect of mercury on the liver cannot be 
 doubted, but scarcely less in amount or importance is its effect upon tlic 
 mucous membrane and glandular follicles of the intestines, the secretions from 
 which are often mistaken for those of the liver." (Holland's " Med. Notes and 
 Reflections ;" cap. on " Mercurial Medicines.")
 
 9G TREATMENT OF ACUTE RHEUMATISM, 
 
 intestinal derangement in a very marked degree. They com- 
 plain of a sour and disagreeable taste in the mouth, and of 
 fullness and distention at the epigastrium ; their conjunctivae 
 are yellowish, their breath is often foul, the tongue inclined to 
 be dry and very furred and yellow, the motions dark colored 
 and offensive, the appetite altogether lost. In these cases 
 there appears to be so much torpidity of the primse viae, such 
 an absence of healthy intestinal secretion, and withal, prob- 
 ably, so large an accumulation, in the s^'stem, of matter Avhich 
 ought to have been excreted by the bowels, that it is expedient 
 to exact at least two full alvine evacuations for the first three 
 or four days of the attack. And they are generally accom- 
 panied by signal relief. The aperients, though administered 
 in full doses, produce no griping, no tenesmus, no appreciable 
 distress ; on the contrary, they are folloAved by copious, dark- 
 colored, offensive dejections, the getting rid of which is evi- 
 dently conducive to the comfort and well-being of the patient. 
 He expresses himself sensible of immediate relief, and the cor- 
 rectness of his sensations is attested by the greater moisture 
 of the tongue, the absence of the previously existing fetor of 
 his breath, and the marked improvement of the general 
 symptoms. 
 
 Thus, then, while I admit the necessity of close attention to 
 the alvine secretions, and, in some instances, would insist upon 
 repeated calls upon their activity, I feel persuaded that active 
 purging is sometimes not only unnecessary, but extremely 
 prejudicial to the safety of the patient. In cases unaccom- 
 panied by those indications of intestinal derangement before 
 alluded to ; in cases in which the bowels are acting freely, and 
 the dejections are healthy and bilious in appearance, pui'ging 
 may be useful as a powerful means of draAving off the poison, 
 but it certainly is unnecessary for the cure of the disease,^ 
 and must not be expected to afford the relief observed to follow 
 
 1 It is doubtless of these cases that Dr. Corrigan speaks, when he gives it 
 as his opinion, that '■ the patient's bowels, if they have not been constipated 
 at the commencement of the attack, may be not only safely, but with beuefit, 
 not disturbed more than once in two days." (" Dublin Med. Journal," vol. 
 xvi, p. 266.)
 
 OR RHEUMATIC FEVER. 97 
 
 its action in those cases which especially call for its employ- 
 ment. Indeed, as already stated, observation would lead to 
 its being reserved for exceptional cases. If there be much 
 intestinal derangement, a cure can hardly be effected without 
 it ; but if there be not, the discomfort and the risk attendant 
 upon its use are such as to induce us to look for some other 
 means of carrying off the rheumatic poison. And as, "in a 
 combination hereafter to be mentioned, an agent exists both 
 powerful and efficient, for the accomplishment of this object, 
 it is seldom necessary to exact an evacuation from the bowels 
 above once in the course of the four-and-twenty hours. Our 
 constant care should be to keep the bowels from being bound, 
 and to avoid purging. 
 
 The remedy which, next to venesection and purging, has 
 been employed most frequently in acute rheumatism, is opium. 
 The symptoms of the disease are so strikingly indicative of 
 irritation and excitement, and are accompanied by pain so con- 
 stant and severe, that the tranquilizing influence of opium 
 seems especially called for. Accordingly it has been given at 
 every period of the disease, sometimes in small, sometimes in 
 very large doses. I believe the ordinary practice has been to 
 administer from two to four grains in the course of four-and- 
 twenty hours, premising a blood-letting, and acting from time 
 to time upon the bowels by calomel and salts and senna. This 
 method of treatment is objectionable, both on theoretical and 
 practical grounds : — theoretically, because it is not conducive 
 to the elimination of the rheumatic poison ; and practically, 
 because it fails in materially alleviating the patient's suffer- 
 ings, and in shortening their duration. In moderate doses, 
 opium has not the slightest influence in calming the nervous 
 system when roused and excited by the agency of acute rheu- 
 matic inflammation ; there is then so much of action and of 
 suffering, that I have known four grains taken daily by a child 
 only ten years old, without the production of any sensible effect 
 beyond that of somewhat alleviating his sufferings ; and if this 
 medicine is to be made available for relief, it must be given to 
 adults in much larger doses.
 
 98 TREATMENT OF ACUTE RHEUMATISM, 
 
 Dr. Cazenave, of Pau, was the first to recommend the exhi- 
 bition of large and repeated doses of opium for the cure of acute 
 rheumatism ; but the physician to whom the profession in this 
 country is indebted for the practice, is Dr. Corrigan, of Dublin. 
 He generally begins with a grain every two or three hours, and 
 recommends that the dose be increased, " both in frequency 
 and 'quantity, until the patient feels decided relief, when it 
 should be kept up at that dose until the disease is steadily de- 
 clining."^ The average quantity required in twenty-four 
 hours, he considers to be about twelve grains ; and even that 
 quantity does not affect the head. Diarrhoea, he says, some- 
 times occurs while the patient is using the opium in full doses, 
 and purgatives are seldom required. In one case no less than 
 200 grains were taken in the course of a fortnight, with mani- 
 fest relief. 
 
 Of this method of treatment I cannot speak from personal 
 experience, inasmuch as by employing other medicines in con- 
 junction with opium, I have seldom been obliged to make use 
 of it so unsparingly. But I can testify most strongly to the 
 value of the sedative in full and repeated doses ; in doses far 
 exceeding in amount the quantity usually administered.^ In 
 the early and most painful stage of the disease, occurring in 
 adults, it may be often given with the greatest advantage to 
 the extent of six or eight grains in the course of twenty-four 
 hours ; and to children may be administered, without the slight- 
 est fear, in half-grain doses, repeated every three or four hours. 
 In doses such as these, when combined with the treatment 
 hereafter to be mentioned, I have never seen it check secretion, 
 or produce the slightest cerebral disturbance ; rarely, indeed, 
 has it even occasioned sleep, but it has calmed the patient's 
 irritability, alleviated his sufferings, and has thus prevented 
 the wear and tear of the system, arising from a long and painful 
 
 1 " Dublin Medical Journal," vol. xvi, p. 266. 
 
 2 " In procuring sleep (and allaying pain) opium is the most valuable remedy 
 we possess, and its use is not to be measured timidly by tables of doses, but by the 
 fulfillment of the purpose for which it is given." (Holland's " Med. Notes ; " cap. 
 
 " On the use of Opiates.")
 
 OR RHEUMATIC FEVER. 99 
 
 illness. More than this, too, I believe it has effected. I am 
 satisfied that in many instances it has materially hastened the 
 period of convalescence, and has lessened the frequency of in- 
 flammation of the heart. Therefore, while I join issue with 
 those who would treat acute rheumatism by opium alone, I 
 admit most fully the advantage of its employment in conjunc- 
 tion with other remedies, and in quantity sufficient to allay or 
 subdue the pain. The amount required for this purpose varies 
 in different cases, and is dependent not only upon peculiar 
 idiosyncrasies, but on the severity of the disease in each par- 
 ticular instance, and the treatment previously and contempora- 
 neously adopted. In cases where opium is employed alone, 
 about twelve grains probably may be required to subdue the pain 
 and pacify the excitement of the nervous system; but with the 
 aid of other remedies, six or eight grains are usually sufficient ; 
 and in some few instances our object may be attained by the 
 exhibition of four or five grains only in the course of four-and- 
 twenty hours. Sure am I that, as a general rule, the continu- 
 ance of pain is the best practical test of the propriety of its 
 administration, and of the extent to which its exhibition is re- 
 quired, and that whether ten or two grains only are needed in 
 the course of the day, it may be given with impunity, and, 
 indeed, with advantage, as long as pain and restlessness con- 
 tinue.' I know of nothing to contraindicate its use, save only 
 the suspension of secretion ; and I am aware of no circumstance 
 calculated to point to its having been given in too large doses, 
 except the supervention of stupor or narcotism. On neither 
 of these points is there the least cause for alarm. The latter 
 symptom will never arise if the medicine be given cautiously, 
 and its operation carefully watched ; and observation has con- 
 vinced me that it suspends secretion in exceptional cases only. 
 
 1 " When given for the relief of acute pain or spasmodic actions, in some 
 parts of the system, it would seem that the medicine, however vague the ex- 
 pression, expending all its specific power in quieting this disorder of the nervous 
 system, loses, at the same time, every other influence on the body. Even the 
 sleep peculiar to opium appeai-s in such instances to be wanting, or produced 
 chiefly in efTect of the relief from suffering." (Holland's " Medical Notes ; " cap. 
 " On the use of Opiates.")
 
 100 TREATMENT OF ACUTE RHEUMATISM, 
 
 Indeed, it appears probable that opium, when given in quantity 
 sufficient to subdue the pain and alhi}'' the irritation, so far 
 from impeding or suspending secretion, conduces, in some in- 
 stances, to its promotion. Certain it is, that in the. excited 
 state of the nervous and vascular systems, arising from the 
 irritation of the rheumatic virus, all the excretory organs, 
 except the skin, perform their function slowly and imperfectly ; 
 the scanty urine, the dark-colored unhealthy motions, and the 
 coated tongue, testify abundantly to this important fact ; and 
 equally certain is it, that during the administration of opium 
 the urine frequently increases in quantity, the motions become 
 more healthy in appearance, and the coated tongue cleaner 
 and less red. So that, on the whole, the treatment by opium 
 is a safer and better plan than the treatment by purgatives, if 
 the bowels have been acting regularly, and still continue to do 
 so ; but the treatment by purgatives is the most efficient and 
 most certain, if the bowels have been previously bound, and 
 still show a disposition to be confined. 
 
 Venesection, then, calomel combined with purgatives, and 
 opium, are the three remedies which have been most generally 
 made use of for the cure of acute rheumatism, and each, in its 
 way, has been found conducive to the well-being of the patient. 
 But there are several other remedies which have been so highly 
 spoken of, and so extensively used, that it will be necessary to 
 advert to their influence on this disease before detailing my 
 method of treatment. I allude to vapor and hot-air baths, and 
 to mercury, antimony, cinchona, colchicura, guaiacum, niter, 
 lemon-juice, alkalies, and their salts. 
 
 Forced perspiration has been always much in vogue as a 
 remedy for acute rheumatism. Formerly, though actually 
 streaming with perspiration — the acid perspiration so charac- 
 teristic of the disease — the patient was made to swallow large 
 doses of antimony, Dover's powder, and other sudorifics ; was 
 placed in a bed covered with blankets, subjected to the heat of 
 hot bottles and hot bricks, and deluged with copious draughts 
 of warm drinks. 
 
 In modern times, though not so carefully, " accinctus ad
 
 OR RHEUMATIC FEVER. 101 
 
 sudorem," the unhappy sufferer has been sweated quite as freely ; 
 vapor and hot-air baths have been substituted for the extra 
 bed-clothes and hot bottles, and guaiacura, Dover's powder, and 
 other sudorifics have been given freely and repeatedly. So 
 copious is the diaphoresis thus produced, that the perspiration 
 has often soaked through the blankets and the mattress, and 
 has formed a pool on the floor. But the experience of all ages 
 is against the adoption of this method of treatment. Sweated 
 almost beyond belief, and exhausted in a corresponding degree, 
 the patient obtains very little relief to his sufferings, and is so 
 much reduced in strength, that he is frequently afflicted by an 
 eruption of sudamina, recovers slowly and imperfectly, often 
 experiences a relapse, and is generally subject for a consider- 
 able time to wandering pains in the limbs. Repeated observa- 
 tion has fully convinced me of the inexpediency of this method 
 of treatment, except in cases unaccompanied by free perspira- 
 tion. In such cases, and in such alone, it may be employed 
 with advantage, but even then it should be omitted directly a 
 free and natural diaphoresis has been established. 
 
 Another plan of treatment, which has been recommended for 
 the cure of acute rheumatism, is the administration of mercury 
 in combination with opium, so as to produce salivation. In my 
 opinion, however, this practice is not only unnecessary, but 
 decidedly prejudicial to the well-being and safety of the patient. 
 AVhen given so as to affect the mouth, mercury proves exceed- 
 ingly depressing, and is sometimes productive of evil conse- 
 quences which may be felt for months, or even years. More- 
 over, it exerts no perceptible influence over the rheumatic 
 poison, nor does it assist in preventing the access of cardiac 
 inflammation ; on the contrary, I have repeatedly observed, 
 with Dr. Macleod,^ " that the rheumatism has continued, 
 although the mouth was affected, while it has speedily subsided 
 on continuing the narcotic and purgatives without the mer- 
 curial." Moreover, pericarditis and endocarditis supervene as 
 readily while the patient is under the influence of mercury as 
 when that drug has not been administered ; and when such is 
 
 1 Ou "Rheumatism," p. 360.
 
 102 TREATMENT OF ACUTE RHEUMATISM, 
 
 the case, we lose the most valuable property of mercury, namely, 
 that of limiting the effusion of lymph on the inflamed surfaces 
 of the heart. Such being the case, mercurial action should 
 never be induced as a cure for an uncomplicated attack of acute 
 rheumatism. 
 
 M. Laennec was a strong advocate for the administration of 
 tartar emetic in full and repeated doses. He says, " there is 
 no inflammation, except inflammation of the lungs, in which 
 tartar emetic is more eflScacious than in articular rheumatism. 
 The medium duration of the disease, under the influence of this 
 remedy, is from seven to eight days; and we know that it con- 
 tinues from one to two months under the treatment of blcedino-, 
 or of ' la mdthode expectante.' " ^ 
 
 Now, admitting most fully the eflScacy of this medicine as an 
 auxiliary to other remedies, I cannot recommend its adminis- 
 tration by itself as a remedy for acute rheumatism. Valuable 
 as arc its powers in moderating local action, it is insuflicicnt of 
 itself to fulfill the conditions essential to a safe and speedy cure 
 of the disease. And not only so. More extended observations 
 have not tended to verify the extraordinary curative powers 
 ascribed to it by M. Laennec; still less have they discovered 
 in what manner any curative influence is exerted. That its 
 virtue is independent of its action as a diaphoretic or diuretic, 
 is fully admitted by M. Laennec, who, while eulogizing its 
 power of subduing the articular inflammation and effusion, 
 suggests that it acts by "promoting the activity of the intersti- 
 tial absorption, more especially when there exists in the economy 
 an excess of energy, of tone, or of plethora." Whatever its 
 mode of action, however, its eflScacy is displayed most strikingly 
 in the cases here alluded to by M. Laennec ; and, therefore, in 
 the young, the active, and plethoric, in whom it serves to obvi- 
 ate the necessity for bleeding or other antiphlogistic measures, 
 it may be employed in conjunction with remedies having more 
 decidedly curative properties. But to the more weakly, and to 
 those whose symptoms are less acute, it often proves extremely 
 
 1 "Traite des Maladies des Poumons et du Coeur," ed. 2, p. 512.
 
 OR RHEUMATIC FEVER. 103 
 
 depressing, and as it is unnecessary for the relief of the local 
 inflammation, recourse should seldom be had to its adminis- 
 tration. 
 
 The administration of bark in acute rheumatism is contrary 
 alike to analogy and to experience. It is inconsistent with the 
 active nature of rheumatic inflammation : it is contraindicated 
 by the intensity of the febrile disturbance, by the full and 
 bounding pulse, the furred tongue, and the loaded urine ; and 
 it is forbidden by the marked aggravation of the symptoms 
 which usually follows its incautious exhibition. It has never- 
 theless been so well spoken of by men whose recommendation 
 is deserving of attention,^ that it may be right to examine 
 somewhat in detail the history of the cases on which such 
 favorable opinions have been founded. 
 
 Dr. Haygarth, one of the most strenuous advocates of this 
 method of treatment, was in the habit of giving doses of from 
 ten to thirty grains of the powder, or from an ounce and a half 
 to two ounces of the decoction of bark, three or four times a 
 day. He generally began to give it between the third and 
 tenth day of the attack, at a time when the articular inflam- 
 mation was most acute, and was accompanied by active febrile 
 disturbance. Yet, he says, " I can only discover five instances 
 in which the bark did not produce manifest salutary eff"ects on 
 its first exhibition." ^ No opinion can be more decided, or more 
 favorable to the influence of the remedy, and none certainly 
 can be in more direct opposition to the result of modern expe- 
 rience. Fortunately, therefore, he has given to the world a 
 record of the cases on which his favorable opinion is based, and 
 from these very cases it is difficult to arrive at any other than 
 an opposite conclusion. Out of the 170 cases of acute rheu- 
 matism which he has recorded, 49 were treated by salines, anti- 
 monials, purgatives, and bleeding, while the remaining 121 
 
 * The cinchona was extensively used by Dr. Haygarth, at the latter end of 
 the last century, and has been sanctioned by the testimony of Dr. Fothergill, 
 Dr. Heberden, Sir George Baker, Sir Walter Farquhar, and other physicians of 
 experience and reputation. 
 
 * "Clinical History of Disease," p. 108.
 
 •104 TREATMENT OF ACUTE RHEUMATISM, 
 
 were treated more or less completely by bark. Out of the 
 whole number, 19^ had symptoms of " phrenitis" and "deli- 
 rium," and of these 19 cases, no less than 17 were met with 
 among those to whom the cinchona Avas administered, a fact 
 which affords a fearful commentary upon this inconsistent and 
 empirical method of treatment. 
 
 In my own practice, bark has never been given at such an 
 early period of the disease, nor have I often seen it so admin- 
 istered by others ; but I have repeatedly watched its adminis- 
 tration at a later period, while the tongue has still continued 
 furred, and the pulse excited; and it has been so constantly 
 followed by a fresh accession of mischief, that I have been 
 deterred from making use of it until the urine has cleared, the 
 pulse has become soft, and the tongue moist and almost clean. 
 Then, more especially in cachectic states of constitution, or in 
 persons who have been much exhausted by the attack, it is 
 often of essential service ; but even under these circumstances 
 its effects must be carefully watched, in order that its adminis- 
 tration may be abandoned at once, should any increased heat 
 of skin, acceleration of the pulse, or coating of the tongue or 
 loading of the urine appear to indicate a recurrence of fever. 
 Indeed, it is only in the very weakly and cachectic that it is 
 ever advisable to have recourse to its employment, for in the 
 great majority of instances quinia is more readily and earlier 
 tolerated ; and as it is quite as efficient as bark, it should have 
 the preference when an eruption of sudamina, the character of 
 the pulse, or the cleaning of the tongue appears to demand or 
 admit of the exhibition of a tonic. It should be used as a cor- 
 rective and restorative of the processes of assimilation when 
 the febrile paroxysm is beginning to abate, rather than as a 
 cure during the active stages of the disease. 
 
 Colchicum is a medicine which has been lauded as much too 
 extravagantly by one class of practitioners, as it has been 
 abused too indiscriminately by another. By some it has been 
 called a specific for acute rheumatism, and by such has been 
 
 ^ In column ix of Dr. Hajgarth's tables, sixteen cases only are menlioned, 
 but three others are to be found in column xvi.
 
 OR RHEUMATIC FEVER. 105. 
 
 exclusively relied on for its cure ; and in proof of its eflScacy, 
 cases have been adduced in which not only has the disease dis- 
 appeared under its influence, but its subsidence has been 
 accompanied by profuse evacuations from the kidneys, the 
 stomach, or the liver, and bowels. The pain has abated, and 
 the pulse has become more tranquil, coincidently with the 
 occurrence of purging, or vomiting, or diuresis.^ 
 
 In stating these facts, I am saying all that can be said in 
 favor of colchicum administered alone for the cure of acute 
 rheumatism. All practitioners will admit, that when it causes 
 purging or vomiting, or excites an abundant flow of urine, it 
 may possibly of itself efi"ect a cure ; but few, I think, are dis- 
 posed to ascribe to it a curative power except under these con- 
 ditions. Purging and vomiting, however, are among the first 
 symptoms of poisoning by colchicum, and are often accompanied 
 by such extreme prostration, and by so much gastro-intestinal 
 irritation, that Avhen it becomes a question whether the cure of 
 the disease can be safely intrusted to colchicum alone, the pru- 
 dent physician very properly hesitates in recommending or 
 adopting so dangerous an expedient. He refuses to rely solely 
 upon a medicine which is apt to produce such disagreeable 
 effects, and tries to discover some method by which he may 
 obtain from it its virtue as a remedy, without running the risk 
 of its action as a poison. 
 
 Now this may be effected by administering it in small doses 
 in combination with other medicines ; and although in this form 
 it may not have the power of curing acute rheumatism, it has 
 at least the property of alleviating its symptoms, and shorten- 
 ing their duration. It does so, I believe, not by operating 
 simply as a sedative, nor by acting specifically upon the rheu- 
 matic virus, but by promoting its evacuation by the kidneys, 
 and by exercising some influence over the process of assimila- 
 tion, whereby the formation of the poison is checked. Be this 
 as it may, immediate benefit so repeatedly results from its 
 administration in conjunction with small doses of calomel, 
 ipecacuanha, alkalies, and opium, and in chronic cases is so 
 
 1 See "London Med. Gazette," June 30, 1838.
 
 106 TREATMENT OF ACUTE RHEUMATISM, 
 
 frequently obtained bj its administration uncombinod with 
 other remedies, and in doses insufficient to produce any sensible 
 eJGTect upon particular organs, that no one can hesitate to assign 
 to it the improvement in the instances alluded to. 
 
 But it is not equally beneficial in all cases of acute rheuma- 
 tism, nor in all forms nor at all stages of the complaint. It 
 is far less efficacious in the weak and nervous, than in the more 
 robust and less easily depressed, and of less value in purely 
 fibrous rheumatism, than in cases complicated by synovial 
 inflammation. In my hands, too^ it has proved less advan- 
 tageous in proportion as the fever has exceeded the articular 
 swelling, and as the urine has been less highly charged with 
 the lithates. 
 
 But though colchicum is of the greatest value in the treat- 
 ment of acute rheumatism, its operation must be Avatched most 
 carefully. Throughout its administration it is impossible to 
 insist too strongly upon the necessity of securing a daily evac- 
 uation from the bowels, and of attending to the other general 
 symptoms of the disease. If the lithates disappear from the 
 urine, if the pulse becomes weak, if faintness, or nausea, or 
 purging supervenes, its use must be instantly discontinued. 
 But until some one of these symptoms occurs, a grain or a 
 grain and a half of the acetous extract or the inspissated juice, 
 or from fifteen to twenty minims of the wine of colchicum, may 
 be administered safely, and with obvious advantage, two or 
 three times a day. 
 
 Of guaiacum I have had considerable experience. I have 
 seen it administered by my colleagues at St. George's Hos- 
 pital, sometimes alone, sometimes in conjunction with other 
 remedies, in a large number of cases, and I have myself pre- 
 scribed it on several occasions with some apparent advantage. 
 Observation, however, has not led me to form a very favorable 
 estimate of its curative power in this particular form of the 
 disease. In persons of a weakly, broken-down constitution, 
 and in subacute cases unaccompanied by the characteristic acid 
 perspiration, it has sometimes proved of essential service in 
 stimulating the action of the skin ; but in most acute cases, if
 
 OR RHEUMATIC FEVER. 107 
 
 it has done no harm, it has eifected little good as compared 
 with other remedies : it has neither appeared to mitigate the 
 symptoms, nor to shorten their duration. 
 
 There is, however, as much diiTerence in regard to the action 
 of this medicine in different cases, and in different doses, as 
 there is in regard to colchicum. Dr. Seymour, who was in the 
 habit of giving the raistura guaiaci of the "Pharmacopoeia" in 
 full and repeated doses, says : " It acts not as a stimulant, but 
 as an evacuant, provoking purging, perspiration, and a flow of 
 urine in a very violent manner : sometimes one, sometimes all 
 these effects follow the use of the medicine."^ Now, in my 
 experience, the beneficial effects of guaiacum in the acute dis- 
 ease are observed precisely under the conditions pointed out 
 by Dr. Seymour ; they are obtained in those cases, and in 
 those alone, which are unaccompanied by perspiration, and in 
 which the excretory organs are greatly excited by the action 
 of the remedy. But in ordinary doses, and under ordinary 
 circumstances, when the patient is perspiring freely, and when 
 it neither purges nor causes diuresis, very little benefit results 
 from its employment.' It neither modifies the local action nor 
 limits its duration ; and as the purging induced by its opera- 
 tion is sometimes most distressing, its exhibition should be 
 reserved for subacute or lingering cases, in which, when it pro- 
 vokes a free perspiration, its beneficial influence cannot be 
 doubted. 
 
 The nitrate of potash has been largely employed for the cure 
 of acute rheumatism, both in this country and on the Continent, 
 in doses varying from a few grains to two or even four drachms 
 three or four times a day. In the smaller quantities I have 
 frequently given it in combination with other remedies ; and 
 on several occasions I have seen it administered to the extent 
 of an ounce in the course of four-and-twenty hours. Generally, 
 it has been without obvious action on the excretory organs, and 
 has exerted little influence over the intensity of the symptoms, 
 or the duration or ultimate issue of the disease. 
 
 • Clinical Lectures, published in the "Medical Gazette," and the " Medico- 
 Chir. Review," vol. xxxiii.
 
 108 TREATMENT OF ACUTE EHEUMATISM, 
 
 Mons. Gendrin in France, and Dr. Basham in tliis country, 
 have been lately adopting the practice recommended by Dr. 
 Brocklesby, in 1764/ of giving large and repeated doses of 
 this salt. Dr. Henry Bennett speaks most favorably of its 
 efficacy as administered by Mons. Gendrin at the Hospital of 
 La Piti^. He states that the salt, Avhen properly administered, 
 "is from the first tolerated in the great majority of cases," 
 but that sometimes "the injection of the solution occasions 
 •slight vomiting." During the first twenty-four or thirty-six 
 hours, very little change is produced in the state of the patient ; 
 but, generally speaking, about that time, sometimes a little 
 later, the pulse diminishes in strength and number, and that 
 ■without any perceptible change in the state of the patient. 
 He has " seen many cases in which the renal secretion has 
 been decidedly increased, and sometimes the excretions of the 
 skin are also much increased ;" and " when this occurs, he has 
 remarked that the pulse falls much more rapidly than when 
 the depressing effect of the salt is alone experienced."^ Dr. 
 Basham also speaks highly of its value when freely admin- 
 istered. " One, two, or even three ounces of it, freely diluted, 
 may" he says "be taken in the twenty- four hours in cases of 
 acute rheumatism, and in the majority of cases without pro- 
 ducing any obvious effect on the force or frequency of the 
 pulse, the integrity of the digestive function, the state of the 
 abdominal organs, or even upon the quantity of urine excreted," 
 'but " it relieves in a marked manner the swelling, heat, and 
 pain of the joints." He has " never seen the nitrate of potash, 
 in large or small doses, produce either nausea or vomiting.^ 
 
 » '' Medical Observations," by Dr. Richard Brocklesby, 8vo. ; London, 1764. 
 The Doctor states " that for diet and sustenance, the patient should be con- 
 fined to the free use of ■vcater-gruel, in each quart of which two drachms of 
 niter were to be dissolved, and when the stomach would allow the quantity 
 of drink, two drachms or more of niter would be taken in the four-and- 
 twenty hours. It usually caused free perspiration, and acted sufficiently as 
 an aperient, and when it failed in this respect, the help of injections was 
 added." 
 
 2 On the Treatment of .Acute Rheumatism by large doses of Nitrate of Pot- 
 ash. ("Lancet" for 1844, vol. i, p. 374.) 
 
 ' Such symptoms nevertheless do sometimes occur. Dr. Robert Barnes 
 reports that " in one case which he watched in the wards of M. Gendrin, alarm-
 
 OR RHEUMATIC FEVER. 109 
 
 In a few cases pinching or griping pains of the abdomen, with 
 a few watery evacuations, which have quickly ceased on dis- 
 continuing the salt, are the only unpleasant or undesirable 
 effects which he has witnessed."^ 
 
 Now I heartily wish I could confirm this favorable report of 
 the curative action of nitrate of potash, but such, unfortunately, 
 is not the case. I have watched its administration to the 
 extent of about an ounce daily, in seventeen cases of acute 
 rheumatism, and to a smaller extent in several others, and in 
 one instance only did it appear to exercise any decided con- 
 trol over the course or duration of the symptoms. In most 
 instances it was readily tolerated by the stomach ; and in the 
 case alluded to gave rise to copious diuresis, with manifest 
 relief to the pain and inflammation ; but in every other instance 
 it was without any obvious effect upon the excretions, and the 
 disease continued of average intensity, and ran on to its ordi- 
 nary duration. Indeed, in the cases reported by Dr. Basham, 
 the patients on the average were four weeks and a half under 
 treatment, and as application is seldom made to a hospital 
 until the patients have been ill some days at home, the average 
 duration of the cases alluded to can hardly have been less than 
 five or six weeks, which is a period of quite the average dura- 
 tion. But as niter, contrary to the observation of Dr. Basham, 
 does appear to exercise a powerful influence over the vascular 
 system,^ diminishes the force and frequency of the heart's 
 action, and controls the tendency to fibrinous deposition by 
 increasing the solubility of the fibrin, it is valuable in acute 
 rheumatism, not so much by effecting a cure of the disease, as 
 by tending to prevent those untoward complications which 
 render it so formidable. 
 
 Lemon-juice, in one or two ounce doses, repeated three or 
 
 ing diarrhcca supervened on the second day, together with vomiting and pain 
 on pressure over the region of the stomach, and increase of febrile move- 
 ment." (" Lancet" for 1844, p. 472.) 
 
 1 On the Nitrate of Potash in Acute Rheumatism. (" Med.-Chir. Trans.," 
 vol. xxxii, pp. 5, 6.) 
 
 ■■^ Mr. Alexander found by experiment, that niter most surprisingly and most 
 rapidly diminishes the frequency of the heart's pulsations. {Vide ''Essays," 
 p. 105, et seq.)
 
 110 TREATMENT OF ACUTE RHEUMATISM, 
 
 four times a day, was introduced as a cure for acute rheuma- 
 tism by Dr. Owen Rees. He supposed that, by the excess of 
 oxygen it contains, it promotes the conversion of lithic acid 
 into urea and carbonic acid, and thereby favors its excretion 
 from the system, while the small quantity of alkaline citrate 
 which it contains, contributes also in some measure toward 
 effecting a cure. A more plausible explanation appears to me 
 to be that its curative effect depends upon its supplying a 
 necessary material to the blood and promoting the oxidation of 
 lactic acid, and its conversion into carbonic acid. Whatever 
 its mode of action, however, the remedy had the advantage 
 both of simplicity and novelty, and accordingly for some time 
 was very generally adopted. But after an ample trial it has 
 now been discarded as uncertain in its action ; and physicians 
 are again content to rely upon a more rational, though more 
 complex, method of treatment. 
 
 The advantages claimed for this remedy by Dr. Owen Rees, 
 are power to moderate vascular action and to afford speedy 
 relief to the rheumatic symptoms. Judging, however, from 
 my limited experience, I cannot conscientiously speak of these 
 effects as the ordinary results of its administration. I have 
 watched its exhibition in twenty-nine patients, and although in 
 several it produced much depression, in some gave rise to 
 griping pains in the abdomen, and in one excited violent diar- 
 rhoea, accompanied by a copious discharge of blood from the 
 bowels, yet in three patients only did it appear to afford relief, 
 or to hasten recovery. 
 
 In the three instances alluded to, it was taken in full doses, 
 viz., eight ounces in the twenty-four hours, and was not only 
 tolerated, but, as far as I could judge, was speedily assimilated 
 in the stomach ; and its influence in quieting the heart's action, 
 in promoting a free evacuation from the kidneys, and in caus- 
 ing subsidence of the articular inflammation, was very marked. 
 But in most cases it did not appear to be readily digested, as 
 was evidenced by the length of time which elapsed before the 
 patient became free from its flavor ; and it is probable that its 
 frequent failure in alleviating the symptoms of the disease
 
 OR RHEUMATIC FEVER. Ill 
 
 may be attributed in part to this cause, and in part to the fact 
 that the blood in many cases requires materials which lemon- 
 juice does not contain or is not capable of supplying. Be this 
 as it may, the results of its administration were anything but 
 encouraging. And on analyzing the cases reported by Dr. 
 Rees, I do not find that he has -obtained a much more favorable 
 result ; for, on the average, his cases were twenty-five days 
 under treatment, and were ill for a period of forty days, a term 
 within which the symptoms will have subsided, and health will 
 have been restored under most methods of treatment. There- 
 fore, without denying that lemon-juice may, in some instances, 
 prove beneficial, I would not generally recommend its employ- 
 ment. If alkalies and the neutral salts cannot be given in full 
 doses, in consequence of their being rejected by the stomach, 
 and if other treatment fails in its object, then perhaps lemon- 
 juice may be tried ; but it is less efficacious in curing the patient, 
 and relieves his suff'erings far less certainly and speedily than 
 does the treatment I ordinarily pursue. 
 
 But thouorh I do not counsel the administration of lemon- 
 
 O 
 
 juice as a medicine on which to rely for the cure of acute rheu- 
 matism, I am of opinion that numerous instances occur in which 
 its influence may be beneficially exerted in aid of other remedies. 
 Many persons adopt a diet which is apt to lead to a deficiency 
 of vegetable acid in the system, and whenever there is reason 
 to suspect such a deficiency, I order lemonade to be taken as a 
 beverage, while the disease is being combated by other means. 
 Nor have I ever had occasion to regret its administration, under 
 the conditions referred to, for it has generally proved grateful 
 to the patient, and apparently serviceable in checking the dis- 
 ease. And although if given indiscriminately it often fails in 
 affording relief, it seldom does harm or occasions discomfort, 
 unless it disagrees with the stomach, in which case its use must 
 be discontinued. 
 
 Of the value of alkalies and their salts in acute rheumatism, 
 it is impossible to speak too highly. Whether regard be had 
 solely to the facts that the normal alkalinity of the saliva dis- 
 appears, that the acidity of the perspiration is excessive, that
 
 112 TREATMENT OF ACUTE RHEUMATISM, 
 
 the urine is surcharged with acid, and that the alvine dejections 
 are also loaded with acidulous matters ; I say, whether regard 
 be had solely to these significant facts, or whether the question 
 be viewed in reference to the occurrence of fibrinous deposits on 
 the valvular apparatus of the heart, alkalies in either case cannot 
 fail to prove useful. They are not only active depurating agents, 
 and corrective of the abnormal condition of the blood and excre- 
 tions, but, in great measure, they are preventive of the depo- 
 sition of fibrin.' Administered alone, however, and in ordinary 
 doses, they are inadequate to efl'ect a speedy cure. The system 
 is so surcharged with acid, that no ordinary doses can restore 
 its alkalinity ; and even when given in doses sufficient to effect 
 this purpose, alkalies in many cases prove unequal to restore a 
 healthy state of assimilation, and to prevent the further forma- 
 tion of acid in the system. Of this I am fully satisfied by ex- 
 perience. The pain may be greatly alleviated, and the force 
 of the febrile and inflammatory symptoms checked, but no cer- 
 tainty can be felt as to arresting the disease without the aid of 
 other medicines to assist in modifying the function of assimila- 
 tion, and to act on the various excretory organs.. 
 
 It will be gathered from what has been already stated, that 
 my chief objection to many of the expedients which have been 
 resorted to for the cure of acute rheumatism, lies not so much 
 against the remedies themselves, as against the mode in which 
 they have been employed. Each remedy or class of remedies 
 has been too exclusively relied upon. There may be occasions 
 in which blood-letting or opium, or calomel and active purging, 
 are necessary ; there may be circumstances which call for the 
 exhibition of guaiacum, niter, colchicum, or other agents ; but 
 it seldom if ever happens that the cure of acute rheumatism 
 can be safely intrusted to any single remedy. For as the dis- 
 ease presents different aspects in different cases, so does it also 
 at different stages in the same individual ; and even were it 
 not so, the constitutional disturbance is so great, the cause of 
 the derangement is so widely spread, and its effects extend to 
 
 * See Simon's " Chemistry," in " Sydenham Society's Publications," pp. 
 116-17.
 
 OR RHEUMATIC FEVER. 113 
 
 such a variety of organs, that every principle of medicine points 
 to a compound method of treatment as most likely to lead to a 
 successful issue. 
 
 The treatment to which I usually have recourse at the outset 
 of the attack, is that alluded to at the beginning of this chapter. 
 It is made up of alkalies and the neutral salts, with colchicum, 
 opium, and if necessary, calomel. Sometimes a little antimony 
 is added, sometimes the aid of purgatives is had recourse to, 
 and occasionally, though rarely, I deem it expedient to premise 
 a moderate blood-letting. Baths are never employed if the skin 
 is acting freely ; but if, insteiad of being bathed in perspiration, 
 it remains dry and hot, and burning, I then endeavor to stimu- 
 late its action by means of the vapor or hot-air baths. 
 
 As venesection, if employed at all in acute rheumatism, is 
 to be made use of with a view of producing an impression on 
 the train of morbid actions, and expediting the operation of 
 other remedies, it must necessarily take the lead of all other 
 measures ; and the first question to be decided, therefore, in 
 every case of acute rheumatism, is as to the propriety of having 
 recourse to its employment. It has been already pointed out, 
 that the use of the lancet is not necessary for the relief of the 
 pain or the tranquilization of the pulse, and that in the pale 
 and weakly it exercises an influence prejudicial to the patient 
 by rendering more irritable his already irritable and excited 
 heart. But in the young, plethoric, and robust, in whom secre- 
 tion is insufficient, whose pulse is full and bounding, and whose 
 skin is dry and hot, and burning, it certainly does assist in 
 expediting the action of other remedies, and, so in promoting 
 recovery. These, therefore, are the only cases in which it 
 should be employed, and a single bleeding of from eight to ten 
 ounces is generally sufficient. It relieves that excessive con- 
 gestion on which the want of secretion, in great measure, 
 depends, and which forms an obstacle to the action of those 
 remedies on which we rely for effecting a cure. 
 
 The next point is as to the expediency of giving calomel and 
 purgatives. If the bowels are acting once a day, it is seldom 
 necessary to make a more frequent call upon their activity, but
 
 114 TREATMENT OF ACUTE RHEUMATISM, 
 
 a dose of calomel and opium may be prescribed with the view 
 of modifying the character of their secretions. If the bowels 
 are sluggish in their action, and the dejections dark colored 
 and offensive, a dose of calomel combined with opium should be 
 administered at once, and followed, after the lapse of six or 
 eight hours, by a draught containing the infusion of senna, toge- 
 ther with half an ounce of the potassio tartrate of soda, and 
 twenty minims of the vinum colchici. And the amount of opium 
 should be so adjusted to the dose of the purgative as to procure 
 one full and copious evacuation without the distress attendant 
 upon purging. 
 
 When once the bowels have been freely acted on, the state 
 of the secretions must be our guide as to the repetition of the 
 calomel and the morning laxative. If the tongue be rather 
 dry ; if the bowels continue sluggish, and the dejections dark 
 colored and offensive, the mercurial and the purgative should 
 be repeated for several successive days. If, on the other hand, 
 secretion from the bowels be healthy, the further exhibition of 
 mercury is unnecessary. If, again, the secretions be copious 
 but unhealthy in character, the calomel and opium should be 
 repeated at night, but need not be followed by a purgative in 
 the morning, as after one or two doses of the mercurial, the 
 motions become lighter colored, more bilious in appearance, 
 and of a less offensive character. 
 
 While the state of the intestinal secretions are thus attended 
 to, alkalies and the neutral salts should be administered in full 
 doses in combination with a few drops of colchicum wine. In 
 some instances ^he addition of opium is necessary, in others a 
 little antimony is useful. At one time I used to content myself 
 by giving a saline draught, with the addition of fifteen or twenty 
 grains of the carbonate of potash, or the carbonate of soda, 
 three or four times in the course of the day ; but it soon became 
 apparent that in order to obtain the full benefit of alkalies, it 
 is necessary to give them in very much larger quantities — in 
 doses proportioned to the extreme acidity of the system.' In 
 
 > Though I speak throughout of the administration of alkalies, I include 
 under this term the neutral salts, such as the potassio tartrate of soda and the
 
 OR RHEUMATIC FEVER. 115 
 
 ordinary doses they generally mitigated the severity of the pain, 
 yet failed in aifording more than partial relief, while in the 
 more important matter of protecting the heart from mischief 
 they often proved inefficacious. Indeed, it was obvious that 
 until the urine and saliva become alkaline, and thus give evi- 
 dence of the full effect of the alkalies on the system, the heart 
 remains exposed to the danger of inflammation. My endeavor, 
 therefore, has ever been to produce this altered condition of 
 the secretions as speedily as possible, and with this view I have 
 administered alkalies in large doses, repeated at short intervals. 
 Nor have I seen reason, on any one occasion, to hesitate in 
 following out this plan of treatment. It has now been pursued 
 in a large number of cases, and in almost every instance has 
 produced the most astonishingly favorable results. The patients 
 have speedily lost their pains, and have proceeded rapidly to con- 
 valescence. In one hundred and six out of one hundred and sixty- 
 eight cases in my note-book, the pulse was tranquilized within 
 forty-eight hours from the commencement of treatment, and in 
 one hundred and ten the pain was lulled, and the local inflam- 
 mation greatly subdued within the same time, while in most of 
 the remaining cases a longer period was required, in conse- 
 quence either of previous constipation, or <of the coexistence 
 of some internal complication. Moreover, among the last 
 hundred and twenty-six cases in which the heart remained free 
 from inflammation at the time the patients were first brought 
 under my care, not a single instance of pericarditis or endocar- 
 ditis has occurred, the heart having been protected by the ad- 
 ministration of the remedies in the manner already pointed out. 
 The form in which I usually prescribe the remedies, is that 
 of an effervescing citrate of potash or ammonia draught with 
 an excess of from forty to sixty grains of the bicarbonate of 
 potash, or bicarbonate of soda, to which, if the patient be a 
 person of average strength and robustness, bathed in profuse 
 
 acetate of potash, which, as pointed out by M. Wuhler, very readily undergo 
 oxidation in the system, and being converted into carbonates or bicarbonates, 
 react on the secretions as alkalies. In large doses they are much more readily 
 tolerated by the stomach than corresponding quantities of the alkaline carbo- 
 nates.
 
 116 TREATMENT OF ACUTE RHEUMATISM, 
 
 perspiration, -with red, swollen, and exquisitely painful joints, 
 a furred tongue, loaded acid urine, and a full and bounding 
 pulse, I usually add a drachm or more of the acetate of potash,^ 
 and ten or fifteen minims of the vinum colchici, or, if the 
 bowels are costive, I give one or two drachms of the potassio 
 tartrate of soda instead of the acetate of potash, taking care 
 to regulate the purgative action of the salt by the administra- 
 tion of a few minims of the tinctura opii, or of Battley's seda- 
 tive solution. This draught is repeated, for the first twelve or 
 twenty-four hours, at intervals of two, three, or four hours, 
 according to the strength of the patient and the severity of the 
 attack. 
 
 Sometimes, more especially if the lungs are implicated, from 
 fifteen to tAventy minims of the vinum antimonii are added, and 
 if the pain is excessive, I prescribe a pill containing from half 
 a grain to a grain, or a grain and a half of opium, or an equiv- 
 alent dose of Dover's powder to be taken once or twice a day, 
 taking care to increase or diminish the quantity of the sedative, 
 according to the circumstances of the case ; on the one hand 
 avoiding constipation and narcotism, and on the other, guard- 
 ing against diarrhoea. 
 
 Formerly, I used to administer the remedies in a simple saline 
 or niter draught, and prescribed an efi"ervescing draught only 
 when the stomach did not easily tolerate large doses of alkalies, 
 
 1 The virtue of alkalies and their salts in rheumatism depends, I believe, 
 upon their power — 
 
 1st. Of acting as restorers of the alkaline condition of the system. 
 
 2dly. Of assisting to maintain the solubility of the fibrin, and thereby pre- 
 venting its deposition on the valvular apparatus of the heart. 
 
 3dly. Of acting most powerfully as sedatives, and calming the action of the 
 heart and arteries. 
 
 4thly. Of increasing the metamorphosis of tissue, and proving active pro- 
 vocatives of an increased secretion of urine, whereby the elimination of the 
 materjes morbi is assisted. 
 
 Whatever their mode of action, however, their effect in restoring the alkalinity 
 of the system, and of allaying the fever and subduing the pain and inflamma- 
 tion, which accompany, if they be not consequent upon, the opposite condition, 
 is very remarkable, as is also their influence in calming the action of the 
 heart and arteries, and in causing an increased flow of urine and a vast aug- 
 mentation in its solid constituents. These facts receive very striking illustra- 
 tion in the cases reported at the end of this Chapter.
 
 OR RHEUMATIC FEVER, 117 
 
 or of the neutral salts. But the addition of lemon-juice and 
 an alkaline carbonate forming a saline effervescing drink, 
 deprives the medicine of so much of its nauseous quality, and 
 renders it so much less liable to derange the stomach, that I 
 now make a practice of ordering each draught to be taken in a 
 state of effervescence. And with this precaution, an instance 
 rarely occurs in which any nausea or discomfort is produced. 
 When once the medicine has begun to take effect, which is 
 evidenced by the gradual decrease of the pain, the tranquili- 
 zation of the pulse, the alkalinity of the urine, and the increase 
 in its quantity and density, the remedies are repeated every 
 fourth hour only, and then every fifth or sixth hour ; and usu- 
 ally at the expiration of two or three days, I find their work in 
 great measure accomplished. Sometimes, indeed, before the 
 expiration of twenty-four hours, the saliva has lost its acidity, 
 the inflammation has subsided, the pain is much subdued ; the 
 pulse has fallen, probably, from 120 to 85 or 90 beats in 
 a minute ; the tongue has become moister and less red and 
 furred ; the urine more abundant, of a higher specific gravity, 
 often clear, and sometimes even alkaline, and the perspiration 
 less acid, less sour smelling, and less profuse. In proportion' 
 as these symptoms of amendment manifest themselves, so is the 
 dose of the alkalies decreased, until, after the lapse of three or 
 four days, I usually feel justified in commencing the adminis- 
 tration of quinia or bark, in combination with small doses of 
 bicarbonate of potash, taking care to maintain a free action of 
 the bowels, by exhibiting, now and then at bedtime, two or 
 three grains of the acetous extract of colchicum, together with 
 aloes or rhubarb, and, if necessary, a grain of calomel or blue 
 pill. Should there be any acceleration of the pulse, the 
 slightest return of pain, the least increase of coating on the 
 tongue, the least loading of the urine, or, indeed, any evidence 
 of returning fever, the use of the tonic is at once abandoned 
 and alkalies are again resorted to. But generally the case 
 proceeds steadily to convalescence, and after a few days the 
 pills are either omitted altogether, or repeated less frequently 
 and in diminished quantities. Sometimes, if there be not much
 
 118 TREATMENT OF ACUTE RHEUMATISM, 
 
 tendency to perspiration, the mistura guaiaci of the Pharmaco- 
 poeia may be administered with the addition of a drachm of the 
 volatile tincture of guaiacum, and thirty or forty minims of 
 liquor potassse, or as many grains of bicarbonate of potash, 
 while if the patient appears to be cachectic, the decoction of 
 cinchona, with the addition of the ammoniated tincture of 
 guaiacum, or half a drachm of the extract of sarsaparilla with 
 three or four grains of iodide of potassium, and twenty or 
 thirty grains of bicarbonate of potash proves a more active and 
 efficient agent. 
 
 But I do not conj&ne myself to internal remedies. I en- 
 deavor to alleviate articular inflammation by means of external 
 topical applications. 
 
 By many persons this practice is regarded as useless, and by 
 some has been condemned, on the ground that, by interfering 
 with the inflammatory action taking place at an aff'ected rheu- 
 matic joint, we incur the risk of disturbing the attraction of the 
 morbid element, and of driving it to some internal viscus. 
 Doubtless, if cold topical applications were to be employed, and 
 the elimination of the poison thus forcibly arrested, a very haz- 
 ardous experiment would be tried, and serious internal mischief 
 would probably arise. But against leeches, blisters, and warm 
 fomentations, this objection cannot be reasonably urged : they 
 do 7iot check the continuance of perspiration; they favor rather 
 than arrest the exit of the morbid matter, and the only fact, 
 therefore, to be ascertained in regard to them, is their remedial 
 or curative power. 
 
 It has been already stated, that rheumatic inflammation very 
 rarely leads to disorganization of the joints, and moi%over dis- 
 plays a remarkable disposition to shift or migrate from one 
 spot to another. Hence leeches and blisters are rarely called 
 for in the acute disease; they are generally unnecessary for tlie 
 relief of the inflammation, and are useless in most cases because 
 of its repeated migration. They might, and indeed they do, 
 afi'ord very marked relief to the severity of the inflammation, 
 but they afibrd no guarantee against its recurrence. Their use, 
 therefore, should be restricted to cases in which inflammation
 
 OR RHEUMATIC FEVER. 119 
 
 lingers about a particular joint, or in wliich the intensity of 
 the action is so great as to threaten the integrity of the struc- 
 tures. But warm fomentations of every description may be 
 always employed advantageously. They soothe the parts, 
 promote perspiration, and thereby favor the elimination of the 
 poison. As the object of the applications is to allay the pain, 
 and counteract the extreme acidity which always accompanies, 
 if it be not the cause of, rheumatic inflammation, it is manifest, 
 theoretically at least, that an alkaline and opiate solution 
 should prove the most eifective remedy. And so in practice it 
 is found to be. I have tried hot water ; I have tried a warm 
 solution of nitrate of potash, as recommended by Dr. Basham ; 
 I have tried a simple alkaline solution; and I have tried a 
 mixed alkaline and opiate solution, and the latter has proved 
 the most powerful in allaying the pain of rheumatic inflamma- 
 tion.' In every instance in which it has been employed, the 
 relief obtained has been almost immediate, and the pain and 
 inflammation have subsided rapidly-. 
 
 That the efi"ect observed to follow these saline fomentations 
 has not been due to accidental causes, is manifest from the 
 result of careful experiment ; for in twenty-two instances in 
 which corresponding joints were afiected, a fomentation of warm 
 water was applied to the one joint, and an alkaline and opiate 
 solution to the other, and almost uniformly the pain and 
 inflammation continued in the former, and speedily subsided 
 in the latter. Besides this, I have endeavored to ascertaia 
 whether the occurrence of inflammation may not be prevented 
 by impregnating the parts with alkaline matter.^ In thirteen 
 cases in^which the knees, and in twelve cases in which the 
 hands were in the first instance unafi"ected, a mixed alkaline 
 
 * The solution I usually' employ is Potassae Carb. or Sodae Garb. 5iv to 5'^j, 
 Liq. Opii sedativi, jj, Glyceriiii, ^ij, Aqiue Roste, ^ix. Sometimes, however, 
 Decoction of Po|)pies is substituted for ihe Liquor Opii and Rose Water. 
 Tliin flannel soaked in one of these mixtures should be applied to the inflamed 
 pnrts, and the whole should then be wrapped up in flannel. In all cases, how- 
 ever, to prove effective, the flannel must be kept sopping tcet, not merely moist. 
 
 * In a practical point of view, the determination of this question is not of 
 much importance; but on theoretical groimds, as bearing upon the occurrence 
 and possible prevention of cardiac inflammation, it is of the utmost moment.
 
 120 TREATMENT OF ACUTE RHEUMATISM, 
 
 and opiate solution was applied to one joint, and a simple water 
 fomentation to the corresponding joint on the other side. In 
 five of the former cases, and in three of the latter, the joint to 
 which water only had been applied became inflamed, while in 
 one instance only did inflammation occur, and that to a very 
 slight extent, in the joint which had been bathed in an alkaline 
 and opiate solution.^ So that my experiments, though not as 
 yet sufiiciently extensive to enable me to speak decisively on 
 the subject, have, as far as they have gone, proved extremely 
 satisfactory. 
 
 One point yet remains to be noticed. While attacking the 
 disease both by internal and external means, it is essential to 
 pay strict attention to the diet. The patient must be kept low ; 
 yet, as there is an excessive drain upon the system, it is expe- 
 dient to allow him more nourishment than would be safe or 
 proper in other inflammatory complaints. Strong beef tea and 
 jelly may be given in moderate quantities ; and with the view 
 of supplying the waste caused by the perspiration, and of pro- 
 moting the dilution and more rapid absorption of the alkaline 
 medicines administered internally, diluents, such as whey, thin 
 gruel, or barley-water, should be taken from time to time, and 
 especially after each dose of the medicine. 
 
 The folloAving cases, which are placed in chronological order, 
 will serve to illustrate my plan of treatment. 
 
 Case I.^ — William Connor, a carpenter, set. 31, was admitted 
 a patient of the Pimlico Dispensary on the 16th of June, 1846. 
 He had already undergone two attacks of acute rheumatism ; 
 the first ran on in spite of treatment for a period of seven weeks ; 
 and the last, which occurred four years ago, after continuing in 
 an acute stage nearly five weeks, was protracted in a subacute 
 
 1 I am indebted to the kindness of my colleagues, Dr. Wilson and Dr. Bence 
 Jones, for several opportunities of trying these experiments. 
 
 2 For the opportunity of seeing and treating this case, I am indebted to my 
 friend Dr. Blackall, Senior Physician to the Dreadnought Hospital Ship, and 
 formerly Physician to the Pimlico Dispensary.
 
 I 
 
 OR RHEUMATIC FEVER. 121 
 
 form for a period of four months. The present attack com- 
 menced on the 12th instant, and was ushered in by chillin'ess, 
 followed, in the course of a few hours, by pain, heat, redness, 
 and swelling of both wrists, the right elbow, and his left knee. 
 The inflammation shifted rapidly from joint to joint, and when 
 I first saw him on the 16th, his right ankle and both his elbows 
 were severely affected. The pain was so excessive that he had 
 been unable to sleep since the commencement of his attack. He 
 was sweating profusely, the perspiration having the sour odor of 
 rheumatism, and standing in large drops upon his forehead. 
 Conjunctivae yellow ; tongue red at the tip and edges, and 
 coated in the center with a thick yellowish-white fur. Bowels 
 reported open ; urine scanty, dark colored, and loaded with 
 lithates ; sp. gr. 1025. Saliva extremely acid. Pulse 116, 
 full, and bounding. Heart's action regular, but its impulse 
 somewhat increased ; a loud systolic mitral murmur, probably 
 of old standing, distinctly heard at the apex. No friction 
 sound, and no praecordial pain. 
 
 I ordered the joints to be fomented with the opiate and alka- 
 line lotion ; restricted his diet to beef tea, milk, and gruel, and 
 prescribed the following medicine : 
 
 ^.. Hydrargyri Chloridi, gr. v; Opii, gr. ij. M. ft. Pilulae duse honl somni 
 sumendae. * 
 
 Haust. SennsB c. Soda; Potassio-Tart., 3i^i eras primo mane sumendus. 
 Liquoris Potassa?, tt^xI ; 
 Potassse Tartratis, 5ij ! 
 Vini Colchici, v\x; 
 Tincluraj Opii, Tilxij ; 
 
 Haust. Potasste Citratis, §jss. M. ft. Haust. 4'* quaque horfi, 
 sumendus. 
 
 11th. — Passed a tranquil night, though without much sleep, 
 and feels in every respect more comfortable to-day. Joints 
 somewhat less swollen and painful. Tongue moist, but coated. 
 Saliva still acid. Bowels have been moved once. Urine more 
 plentiful, (reported about 1| pints,) less loaded ; sp. gr. 1028. 
 Pulse 96. Heart's sounds the same as yesterday. 
 
 To continue the draught and fomentations as before. 
 To take two grains of Opium at bedtime. 
 9
 
 122 TREATMENT OF ACUTE RHEUMATISM, 
 
 18th. — Passed a quiet night, and slept nearly five hours. 
 
 Joints still slightly swollen, but scarcely at all painful. Still 
 
 perspires freely. Conjunctivae yellowish. Tongue moist and 
 
 cleaning rapidly. Saliva faintly acid. Bowels have not been 
 
 relieved. Urine about 3|^ j)ints, clear, acid ; sp. gr. 1026. 
 
 Pulse 80, soft. Heart's action regular, and sounds just as on 
 
 admission. 
 
 To repeat the medicine every six hours. 
 To take the pills and Senna draught, as ordered on the 16th. 
 
 19th. — Slept well, and is rapidly improving in every respect. 
 There have been two full evacuations from the bowels; the tongue 
 continues to clean, and is no longer red ; and the urine is re- 
 ported about the same as yesterday ; none has been saved for 
 examination. Pulse 76, rather weak. 
 
 To repeat the medicine twice a day. and to take a grain of Opium at 
 bedtime. 
 
 20th. — Slept soundly last night, and to-day is free from pain 
 and swelling of the joints, slight stiffness and uneasiness alone 
 remaining about the right wrist. Tongue quite clean and moist. 
 Bowels somewhat costive. Urine very abundant, clear, and acid ; 
 sp. gr. 1027. Pulse 64, and somewhat weak. Is up and dressed 
 to-day, but feels very low. 
 
 To omit the saline medicine, and take the following : 
 J^. Quinae Disulphatis, gr. ij ; 
 Sulphatis Magnesiae, 5ss ; 
 Acidi Sulphurici dil., ff^v ; 
 Tincture Aurantii, 3ss ; 
 
 Aquae destillata. 3JSS. Ft. haustus bis die sumendus. 
 Haustus Senna; c. Soda? Pota?sio-Tart.. '^'iv, eras mane. 
 Fish and beef tea. 
 
 From this time he proceeded steadily to convalescence ; and 
 on the 24th was so far improved that he asked leave to be 
 allowed to resume work. He was induced, however, to take 
 the Quinia for a few days longer ; but on the 26th he felt so 
 thoroughly well that he betook himself to his ordinary occupa- 
 tion.
 
 OR RHEUMATIC FEVER. 123 
 
 Case II. — William Made, a thin, pale, unhealthy-looking 
 boy, set. 15, was received as a patient under my care at St. 
 George's Hospital, on the 24th of August, 1850. He had got 
 wet through on the morning of the 21st, and in the evening of 
 the same day had been attacked with shivering, succeeded by 
 wandering pains in the limbs. In the course of a few hours 
 the pain seized upon the joints, and the right hand and wrist, 
 the left knee and both ankles became inflamed and swollen. 
 The inflammation, however, had shifted rapidly from joint to 
 joint ; and when I first saw him, his left hand and wrist, the 
 right knee and elbow, and his left ankle were the inflamed 
 parts. He had been unable to sleep since the beginning of the 
 attack, his complexion was sallow, the countenance distressed, 
 and he was sweating profusely. Tongue white and furred. 
 Bowels costive. Urine scanty, high colored, and loaded with 
 lithates ; sp. gr. 1020. Pulse 126, full and bounding, but not 
 strong. Heart's action regular, the sounds distinct and free 
 from murmur. Saliva strongly acid. He had no hereditary 
 tendency to rheumatism, (?) and the present was his first attack. 
 The inflamed joints were at once wrapped up in flannels, 
 soaked in a lotion formed by dissolving an ounce of the carbo- 
 nate of potash in a pint of decoction of poppies ; his diet was 
 limited to beef tea, gruel, and arrow-root ; and the following 
 medicines were prescribed : 
 
 I^. Hydrargyri Chloridi, 
 
 Pulveris Doveri, aa, gr. iij. M. ft. Pulvis statim sumendus. 
 Haustus Seunie c. Sodae Potassio-Tart., 3''J! P^st boras quinquo. 
 
 Haustiis Salini, §j<s ; 
 
 Soda; Potassio-Tartratis, 3'j ; 
 
 Vini Colchici, Tt^xv ; 
 
 Tincturae Opii, fH.^'U- M- ft- Haust. G*" quaque hora sumendus. 
 
 August 25th. — Passed a tranquil night, though without much 
 sleep, and to-day is comparatively easy. The redness has 
 almost disappeared, and the swelling has subsided considerably. 
 Bowels acted on twice by the medicine yesterday, and to-day 
 have been freely moved once. Perspiration still very profuse 
 and acid. Urine about 1^ pints, besides what was passed at 
 stool; acid; less high colored and loaded; sp. gr. 1031.
 
 124 TREATMENT OF ACUTE RHEUMATISM, 
 
 Tongue moist and much cleaner. Pulse 98, soft. Heart's 
 sounds clear. Saliva still acid. 
 
 Rep. Haustus C'* qu&que hora. 
 ^. Pulv. Ipecac, comp., gr. x; 
 
 Hydrarg. Chloridi, gr. iij. M. ft. Pulvis hac nocte sumendus. 
 
 26^7?. — Slept well last night ; to-day has neither redness nor 
 swelling of the joints, and slight stifiFness only remains. Still 
 perspiring freely. Bowels have acted once. Tongue moist, 
 and cleaning rapidly. Urine reported about 2| pints, clear 
 and acid ; sp. gr. 1030. Pulse 86, soft. No exocardial or 
 endocardial murmur. Saliva neutral. 
 
 Rep. Haustus ter die tantum. 
 
 27<A. — Passed another quiet night, and has no return of pain. 
 Bowels have acted once. Tongue quite clean, except just in 
 the center, where it is rather white. Urine clear, and in great 
 abundance ; sp. gr. 1030. Pulse 76, soft. Is up and about 
 to-day. 
 
 ^. Haustus Quinse c. Acid. Sulph. dil., Ti\xv, Sulph. Magnesise, 5ss, bis 
 die. 
 
 From this time he continued taking the quinia until the 30th, 
 when, having had no return of pain, and feeling quite well, the 
 medicine was discontinued. 
 
 Case III. — Samuel Bates, a porter, set. 86, was admitted 
 into the King's Ward of St. George's Hospital, on the 9th of 
 September, 1850. His father was a martyr to rheumatism, 
 and he himself, about seven years ago, underwent an acute 
 attack of the disease, which confined him to bed above two 
 months. Nine months ago he suffered from lumbago during 
 the space of three weeks, but on no other occasion had he ex- 
 perienced any symptom of rheumatism since his former illness. 
 The present attack, which commenced on the 4th instant, was 
 preceded for a week by loss of appetite, languor, and inability 
 to apply himself to work. Shivering, followed by fever, super- 
 vened ; and, in the course of twenty-four hours, several of his
 
 OR RHEUMATIC FEVER. 125 
 
 joints became red, swollen, and exquisitely painful. Since that 
 time, the pain and swelling have shifted repeatedly from limb 
 to limb, and he has had scarcely an hour's sleep. 
 
 On admission, the left knee, the right foot and ankle, and 
 the left wrist and elbow were inflamed and swollen ; there was 
 profuse perspiration of a peculiarly strong empyreumatic 
 odor, and he complained greatly of thirst. The heart's action 
 was regular, and the sounds were clear. Tongue furred, and 
 red at the tip and edges. Saliva acid. Bowels reported open. 
 Urine scanty, and loaded with lithates ; sp. gr. 1023. Pulse 
 126, full and strong. 
 
 The inflamed joints were fomented with an alkaline and 
 opiate solution, and the following medicines were ordered : 
 
 IJ. Hydrargyri Chloridi, gr. iv ; 
 Ext. Aloes Aquosi, gr. iij ; 
 Extract! Colchici Acet., gr. jss ; 
 Opii, gr. ij. M. ft. Pilulae duae statim sumendae. 
 
 Sodae Potassio-Tartratis, ijss ; 
 Vini Colchici, iHxij ; 
 Tincturae Opii, v\x; 
 
 Haustus Potassae Citratis, §jss. M. ft. Haustus tertia quaque hor& 
 sumendus. 
 Pulv. Ipecacuanhoe, gr. xv, hora somni. 
 Barley-water as a drink, beef tea and arrow-root. 
 
 September 10th. — Passed a quiet but sleepless night. Joints 
 still inflamed, though less so than yesterday. Perspiration 
 continues. Heart sounds clear and action regular. Pulse 110. 
 Bowels acted last night, but have not done so to-day. Tongue 
 less red. Saliva still acid. Urine in larger quantity (IJ 
 pints) loaded with lithates; sp. gr. 1023. Revolts at the 
 medicine, which causes excessive nausea, but has not given rise 
 to vomiting. 
 
 Rep. Pulveris Doverl, gr. xv, hora somni. 
 ^.. Potassae Bicarbonatis, 5j ; 
 
 Sodae Potassio-Tartratis, 5jss ; 
 Vini Colchici, Tt^x ; 
 Tincturffi Opii, "Hl^i'j i 
 
 Haustus Potasste Citratis, ^jss. M. ft. Haustus c. Acid. Citrici, 3ji, 
 tertia quaque hora sumendus. 
 Haustus Sennae c. Sod^ Potassio-Tartratis, 3'^; eras mane.
 
 126 TREATMENT OF ACUTE RHEUMATISM, 
 
 11th. — Slept four or five hours last night, and feels easier in 
 
 every respect to-day. Still perspires profusely. No joint 
 
 swollen except the knee, and that only slightly so, but the 
 
 ■whole body feels very stiff. Heart unaffected. Pulse 84, 
 
 soft. Tongue much cleaner and less red, saliva neutral. Bowels 
 
 have acted freely twn'ce, urine clear, plentiful, (about three 
 
 pints,) slightly acid; sp. gr. 1028. Medicine no longer gives 
 
 rise to nausea. 
 
 Repet. Pulvis Doveri hora somni. 
 Repet. Haustus, 4^ quaque hora. 
 
 12th. — Slept soundly last night, and has no longer any 
 swelling or inflammation of the joints. His only complaint is 
 of stiffness. No endocardial or exocardial murmur. Pulse 80, 
 soft. Tongue moist and almost clean. Saliva alkaline. Bowels 
 not open. Urine very abundant, a chamber-pot full; sp. gr. 
 1029. Slightly alkaline from fixed alkali. Skin still per- 
 spiring, but not profusely as before. 
 
 ^. Ext. Colchici Acet., 
 Hydrargyri Chloridi, 
 Ext. Aloes Aquosi, aa gr. ij ; 
 
 Opii, gr. ss. M. ft. Pilulae duraj hora somni sumendae. 
 Repetatur haustus ter die tantum. 
 
 liith. — Passed a quiet night and slept soundly. No longer 
 perspires. No return of pain or swelling. Complains of being 
 hungry, and wishes to get up. Tongue clean. Bowels freely 
 open. Urine clear, abundant, slightly alkaline from fixed 
 alkali; sp. gr. 1030. 
 
 Repetatur haustus bis die tantum. 
 Fish diet. 
 
 14:th. — Is up and dressed to-day. His only complaint is of 
 stiffness of the shoulders and general weakness. Tongue clean. 
 Bowels open. Urine slightly acid. 
 
 11 th. — Quite well, but weak. Tongue clean. Bowels regular. 
 
 Omittatur haustus saliuus. 
 J^. Haustus Quinse, bis die. 
 Ordinary diet, without beer. 
 
 From this time he progressed favorably. On the 24th, after 
 walking in the garden he had slight stiffness about the shoul- 
 
 i
 
 OR RHEUMATIC FEVER. 127 
 
 ders, which was at once relieved by a vapor bath, and with 
 this exception he experienced no drawback — and he remained 
 so free from pain that it was judged safe to let him leave the 
 hospital on the 2d of October. 
 
 Case IV. — Frank Hatcher, set. 16, was admitted into the 
 York Ward of St. George's Hospital, on the 27th of February, 
 1856. He had been seized on the 23d instant, with violent 
 rigors, followed by wandering pains in the limbs, pain, swell- 
 ing, and redness of the joints, and excessive feverishness. The 
 pains had shifted rapidly from joint to joint, so that during 
 the four days which had elapsed since his seizure, almost all 
 the joints had been severely visited. He had been unable to 
 sleep throughout, and had been constantly bathed in profuse, 
 sour-smelling perspiration. 
 
 When I first saw him after admission, his knees, ankles, and 
 the left wrist and elbow were inflamed, swollen, and extremely 
 painful; he was sweating profusely, the perspiration having 
 the peculiar acid odor of rheumatism. The pulse was 124, 
 full, but not hard. Tongue furred and red. Saliva acid. 
 Urine very scanty, high colored, and loaded with lithates ; sp. 
 gr. 1022. Bowels costive. Conjunctivae yellow. He had 
 much thirst, and total loss of appetite. Heart's action regular, 
 and its sounds clear. He had no hereditary tendency to 
 rheumatism, nor had he experienced a previous attack. 
 
 Beef tea and gruel were ordered as food ; barley-water was 
 given as a beverage. The joints were fomented as usual; and 
 the following medicines were prescribed : 
 
 ^. Hydrarg. Chloridi, gr. v ; Ext. Colchici Acet., gr. iij ; Opii, gr. ss. 
 M. ft. Pilulie dua; statim sumendoe. 
 Haust. SennaB c. Sodto Potassio-Tart., 5'j; P^st horas quatuor. 
 Potassse Bicarbonatis, 5J ; 
 Sodte Potassio-Tartratis, 5jss ; 
 Vini Colchici, T^x ; 
 Tincturse Opii, Hlviij ; 
 
 Haust. PotassEe Citratis, §jss. M. ft. Haustus 4'* quaque bora sumen- 
 dus c. Acidi Citrici, 3j.
 
 128 TREATMENT OF ACUTE RHEUMATISM, 
 
 August 2Sth. — The bowels acted freely after the medicine, 
 but he has passed a restless night, sweating profusely, and the 
 pains are still severe, but the swelling and redness are sub- 
 siding. Heart unaffected. Pulse 104, less full and bounding. 
 Tongue much the same as yesterday. Urine much more abund- 
 ant, but still loaded with lithates; sp.gr. 1024. Saliva neutral. 
 
 Repetatur haustus 3"* quaque hora. 
 Haust. Morphise, §iij, hora somni. 
 
 Repetatur haustus Sennffi eras mane. 
 
 February 29th. — Passed a good night, and is much better 
 
 to-day. Still perspiring freely. The left knee only remains 
 
 swollen, and is not very painful. Heart sounds clear. Pulse 
 
 80, soft. Tongue much less red, and almost clean. Bowels 
 
 open, but not freely. Conjunctivae rather yellow. Urine 
 
 abundant, 2^ pints, clear, slightly alkaline, from fixed alkali ; 
 
 sp. gr. 1028. Saliva alkaline. Begins to ask for more food. 
 
 Repetatur haustus 4** quaque hora. 
 Repetantur Pilulae nuper prajscriptaj hue nocte. 
 
 March 1st. — Has passed a quiet night, though without much 
 sleep. No swelling remains, and but little pain. Heart's 
 action regular; sounds clear. Perspiration continues, and is 
 still acid. Bowels have acted freely. Tongue clean and much 
 less red. Urine abundant; still rather alkaline; sp. gr. 1028. 
 Saliva alkaline. 
 
 Repetatur haustus 6'* quaque hora. 
 
 Zd. — No longer any pain. Complains of being hungry, and 
 
 wishes to get up and dress. Tongue clean. Bowels regular. 
 
 Urine abundant, clear, and almost neutral. Skin moist, but 
 
 not bathed in perspiration as before. 
 
 Repetatur haustus. 
 Fish diet ; to keep in bed. 
 
 5th. — Still continues free from pain. No longer perspires. 
 
 Repetatur haustus ter die tantum. 
 
 May get up and dress to-day. 
 
 From this time until the 10th the medicine was continued as 
 a precautionary measure three times a day, but as he then 
 remained quite free from pain, all medicine was discontinued,
 
 OR RHEUMATIC FEVER. 129 
 
 and ordinary diet was prescribed. With the view, however, of 
 guarding against the recurrence of the disease, he was kept in 
 the hospital until the 19th, when, as he was still free from any 
 symptom of rheumatism, he was permitted to return home. 
 
 Case V. — Mary Wood, set. 15, was admitted into Queen's 
 Ward on the 1st of July, 1857. Six days previously she had 
 been seized with wandering rheumatic pains, followed, in the 
 course of twenty-four hours, by pain, redness, and swelling of 
 the knees, ankles, and right wrist. She had never before 
 experienced an attack, and could not account for her present 
 seizure ; but her mother admitted that she had been " off her 
 feed" during the previous six or eight days. Since the com- 
 mencement of her illness she had been unable to obtain a 
 "wink of sleep." 
 
 On admission, her face was pale, the skin hot, but not per- 
 spiring. Tongue furred. Saliva acid. Bowels reported open. 
 Urine scanty, high colored, acid, and turbid ; sp. gr. 1023. 
 Pulse ] 20, full and bounding. The catamenia had not appeared. 
 The heart's sounds were free from murmur. The left knee, 
 both ankles, and the right wrist were hot, red, swollen, and 
 painful. 
 
 An alkaline and opiate fomentation was ordered for the 
 joints; and, as the skin was not acting freely, I prescribed a 
 vapor bath in the evening. The following medicines were also 
 given : 
 
 ^. Extract! Colchici Acetici, gr. ij : 
 
 Pilulae Colocynth c. Calomelane, gr. viij. M. ft. pilulae duae horfi, 
 
 somni htlc nocte sumendae. 
 Potassae Acetatis, 3ij ; 
 Potassse Bicarbonatis, 5j j 
 Vini Colchici, ir^viij. 
 
 Haustus Acetatis Ammonias, ^iss. M. ft. haustus 4** quaque horfl, 
 sumendus c. Acidi Citrici, 3j. 
 Beef tea. 
 
 2d, — The vapor bath acted well, and she has ever since per- 
 spired freely. No sound sleep, but dozed at intervals during
 
 130 TREATMENT OF ACUTE RHEUMATISM, 
 
 the night. Pains much easier, and the joints, though swollen, 
 arc no longer red. Tongue cleaner. Bowels have acted freelj. 
 Urine plentiful, clear, slightly acid ; sp. gr. 1026. Pulse 108, 
 soft and regular. Heart's sounds clear. 
 
 Sd. — Slept better last night, and has less pain than yester- 
 day. Still perspires profusely. Tongue white, but moist, and 
 clean at the tip and edges. Bowels have not acted. Urine 
 abundant, alkaline ; sp. gr. 1026. Pulse 84, soft. Heart's 
 sounds clear. 
 
 Repetatur haustus ter die tantum. 
 Repetantur pilulaj hue nocte. 
 
 4:th. — Slept tolerably well last night. Has still some uneasi- 
 ness in the right knee, but in no other part of the body. 
 Bowels have acted freely. Tongue almost clean. Urine still 
 alkaline, about 2| pints ; sp. gr. 1026. Pulse 72, weak. The 
 last dose of the medicine made her vomit. 
 
 ]^. TincturiE Guaiaci Ammon., 5J ', 
 Potassae Acetatis, 33S ; 
 Liquoris Potassce, Sss ; 
 
 Haustus CinchontB, 5xss. M. ft. haustus ter die sumendus. 
 Fisii and beef tea. 
 
 From this time her progress toward recovery was steady and 
 rapid. On the 7th I deemed it safe to prescribe meat ; on the 
 9th she was permitted to get out of bed and dress ; and on the 
 16th, as she remained quite free from pain, she was allowed to 
 leave the hospital. 
 
 Case VI. — Timothy Suter, aet. 29, was admitted into the 
 Hope Ward of St. George's Hospital on the 2d of July, 1859. 
 A groom by occupation, he had been somewhat languid, but 
 not notably out of health until five days prior to his admission, 
 when he was seized with wandering rheumatic pains, and swell- 
 ing of the larger joints. Feverish symptoms then ensued ; he 
 lost his appetite, became restless and unable to sleep at night, 
 and began to perspire profusely. The present was his first 
 attack, and it was not preceded by rigors.
 
 OR RHEUMATIC FEVER. 131 
 
 I saw him the first day after admission, when his face was 
 flushed, the conjunctivae Avcre yellowish, the skin was hot, and 
 perspiring profusely, the perspiration emitting a strong empy- 
 reumatic odor ; tongue coated and rather dry in the center, 
 saliva acid, bowels reported costive, urine scanty, high colored, 
 and charged with lithates ; sp. gr. 1021. Pulse 110, regular, 
 full, and hounding. The wrists, elbows, knees, and ankles 
 were all much swollen, red, and exquisitely painful. He was 
 complaining of pain in the region of the heart, and a systolic 
 aortic murmur was audible at the base. 
 
 As the pulse was regular, and the other symptoms did not 
 appear to indicate active mischief about the heart, I merely 
 ordered the joints to be fomented as usual, and prescribed the 
 following medicines : 
 
 I^. Extract! Colchici Acetici, gr. ij ; 
 
 Pilulie Colocynth c. Calomelane, gr. viij. M. ft. pilulae du£e hord 
 
 somni hac nocte sumendse. 
 Potassas Bicarbonatis, 5iss; 
 Sodse Potassio-Tartratis, 3'j ; 
 Vini Colchici, Til^x; 
 
 Haustus Acetatis Ammoniaj, §ij. M. ft. haustus 4'* quaque hord 
 sumendus c. Acidi Citrici, 3j. 
 Beef tea. 
 
 ^th. — He had passed a restless night, but his joints were no 
 longer red, and were less swollen and much less painful. The 
 bowels had not acted. Tongue furred, yellowish, and somewhat 
 dry in the center. Urine about a pint and a half, sp. gr. 1024, 
 acid, no longer loaded with lithates. Perspiration still profuse. 
 Pulse 96, regular. Heart's sounds as before. 
 
 The mixture was ordered to be repeated, and the following 
 medicines were also prescribed : 
 
 Hydrargyri Chloridi, gr. iij ; Opii, gr. j. M. ft. pilula statim 
 
 sumenda. 
 Haustus Sennaj c. Sod« Potassio-Tartratis, "^'ix ; post horas tres. 
 
 bth. — The bowels acted freely after the senna, and he slept 
 at intervals throughout the night. The joints are far less 
 swollen and painful, so that he can move in bed without assist- 
 ance. Tongue moist and coated, but cleaning at the edges.
 
 132 TREATMENT OF ACUTE RHEUMATISM, 
 
 Bowels open. Urine still acid, but clear, more abundant, 
 about 2h pints ; sp. gr. 1028. Pulse 92, soft and regular. 
 Heart's sounds as before, but murmur less loud. 
 
 Repetatur baustus 4'" quaque hora. 
 
 6th. — Passed a fair night, and has not much pain remaining. 
 Still perspires freely. Tongue much cleaner. Bowels rather 
 relaxed. Pulse 80, soft and regular ; urine clear, but alkaline. 
 Its amount could not be ascertained, as so much was passed at 
 stool. Heart's sounds as before. 
 
 Repetatur haustus ter die tantum. 
 
 1th. — Slept soundly, and feels quite well to-day. No longer 
 
 any pain. Tongue cleaning. Bowels freely open. Urine 
 
 abundant, turbid, alkaline. Pulse 76, weak. 
 
 Repetatur haustus bis die tantum. 
 Fish and beef tea. 
 
 9th. — No return of pain. Tongue nearly clean. Urine still 
 slightly alkaline. Is up and dressed to-day. 
 
 Omittatur haustus salinus. 
 ^. Haustus Quina? c. Sulph. Magnesias, 5ss ; bis die. 
 
 lOih. — Continues well. 
 
 Ordinary diet. 
 
 A systolic murmur still remained at the base of the heart, 
 but it was very slight, and soft in character. In otlier respects 
 he was quite well, and he was therefore permitted to leave the 
 hospital on the 13th of July. 
 
 The cases above detailed afford sufficient illustration of the 
 effects produced by the plan of treatment above laid down. 
 Its influence over the pulse and the urinary secretion is seen 
 to be most rapid and striking, as is also its power of subduing 
 the pain and arresting the progress of the inflammation. 
 
 In Case I — The pulse fell from 116 to 80 within 48 hours, 
 and to 76 on the third day. 
 " The urine, from being scanty and loaded, 
 
 became plentiful and less loaded within 24 
 hours ; and still more abundant and clear, 
 sp. gr. 1026, in 48 hours.
 
 OR RHEUMATIC FEVER. 133 
 
 In Case I — The inflammation of the joints was almost sub- 
 dued at the expiration of 48 hours, and 
 subsided altogether by the fourth day. 
 
 In Case II — The pulse fell from 126 to 86 in 48 hours, and 
 to 76 on the third day. 
 " The urine, from being scanty and loaded, 
 
 became abundant and less loaded in 24 
 hours, and still more abundant and clear, 
 sp. gr. 1080, in 48 hours. 
 " The articular inflammation was greatly relieved 
 
 within 24' hours, and subsided altogether 
 within 48 hours. 
 
 In Case III— The pulse fell from 126 to 110 in 24 hours, 
 and to 84 within 48 hours. 
 " The urine, from being scanty and loaded with 
 
 lithates, became much more abundant on 
 the second day ; and very plentiful and 
 clear, sp. gr. 1028, on the third day. 
 " The inflammation of the joints began to subside 
 
 within 24 hours, and had almost wholly 
 ceased within 48 hours. 
 
 In Case IV — The pulse fell from 124 to 104 in 24 hours, 
 and to 80 in 48 hours. 
 " The urine, from being very scanty, high colored, 
 
 and loaded with lithates, sp. gr. 1022, 
 became much more abundant, sp. gr. 1024, 
 in 24 hours ; and very plentiful and clear, 
 sp. gr. 1028, in 48 hours. 
 " The pain, redness, and swelling of the joints 
 
 were much reduced in 24 hours, and were 
 altogether subdued within three days. 
 
 In Case Y—The pulse fell from 120 to 108 in 24 hours, and 
 to 84 in 48 hours. 
 " The urine, from being scanty, high colored, 
 
 and turbid, sp. gr. 1023, became much more 
 abundant, clear, and only slightly acid, sp. 
 gr. 1026, in 24 hours, and still more abund- 
 ant, alkaline, sp. gr. 1026, in 48 hours.
 
 134 TREATMENT OF ACUTE RHEUMATISM, 
 
 In Case V — The articular injiammation was greatly reduced 
 within 24 hours, and subsided altogether 
 within three days. 
 
 In Case VI — The pulse fell from 110 to 96 within 24 hours, 
 to 92 within 48 hours, and to 80 within 72 
 hours. 
 " The U7'{ne, which at first was scanty, charged 
 
 with lithates, sp. gr. 1021, increased in 
 quantity, and became almost clear within 
 48 hours, and still more abundant and quite 
 clear, sp. gr. 1028, on the third day ; on 
 the fourth day it became alkaline. 
 " The articular inflammation was considerably 
 
 reduced by the end of the third day, and 
 had subsided altogether by the end of the 
 fourth day. 
 
 These results must not be regarded as exceptional in their 
 character. The cases have been selected, not on account of 
 their favorable issue, but as average examples offering good 
 illustrations of the acute disease, and of the means employed 
 to subdue it. 
 
 On analyzing 168 cases which I have treated, after the plan 
 above detailed, I find that 31 were accompanied by symptoms 
 of endocardial or exocardial inflammation ; but that in 5 only 
 did such symptoms manifest themselves after the commence- 
 ment of treatment, and that before the full effect of the reme- 
 dies could be felt. Excluding these 31 cases, the pulse in 34 
 instances fell between 20 and 30 beats within thirty hours, and 
 to the same extent within forty-eight hours in 72 others ; in 16 
 it was not subdued to such an extent until the expiration of 
 three days ; in 5 not until the fourth day ; in 2 not until the 
 fifth day ; and in 4 not until the sixth day of treatment. In 4 
 cases the precise frequency of the pulse after the first forty- 
 eight hours was not noticed. In 122 instances it had fallen 
 below 92 before the expiration of the third day of treatment. 
 
 There was a great increase in the quantity of the urine by
 
 OR RHEUMATIC FEVER. 135 
 
 the end of twenty-four hours in 39 cases, by the end of forty- 
 eight hours in 56 cases, and by the end of the third day in 10 
 cases ; while in 3 instances in which diarrhoea supervened, the 
 urine remained scanty until after the complete subsidence of 
 the disease. In 29 cases the urine was not saved, and there- 
 fore the quantity voided could not be ascertained. 
 
 In 37 cases the urine became clear within twenty-four hours, 
 in 51 within forty-eight hours, in 13 within three days, in 5 
 within four days, and in 2 on the fifth day. In 29 cases the 
 urine was not saved, and therefore this point could not be 
 determined. In several of these it probably remained turbid 
 for a longer period. 
 
 It lost its acidity, and became either alkaline or neutral, 
 within twenty-four hours in 14 instances ; on the second day, 
 in 44 instances ; on the third day, in 12 instances ; on the fourth 
 day, in 15 instances; and subsequently to that period, in 4 
 instances. In 19 instances it never altogether lost its acidity, 
 and in 29, as the urine was not saved, the fact could not be 
 ascertained. 
 
 The pain was relieved, and the articular infiammation greatly 
 subdued within twenty-four hour.s in 54 cases, within forty- 
 eight hours in 56 other cases, within three days in 15 cases, 
 within four days in 9 cases, and within five days in 3 cases. 
 
 The articular inflammation subsided altogether within twenty- 
 four hours in 7 instances, within forty-eight hours in 26 
 instances, within three days in 33 instances, within four days 
 in 20 instances, within five days in 13 instances, within seven 
 days in 14 instances; and in the remaining 24, although it did 
 not wholly subside until a later period, yet it did not display 
 any symptoms of activity after the fourth day. 
 
 In 7 instances only did the medicine produce any disagree- 
 able effect. In all these it gave rise, in the first instance, to 
 nausea, and in 2 to occasional vomiting. In 3 of these 7 cases 
 the nausea subsided after the first few doses ; in the other four, 
 which were among those in which the articular inflammation 
 was not wholly subdued until the end of the seventh day or 
 afterward, the salines had to be omitted, not only on account
 
 136 TREATMENT OF ACUTE RHEUMATISM. 
 
 of the continued nausea, but because of their purgative action. 
 These were invariably the cases in Tvhich the remedial power 
 of the salines was least strikingly displayed ; and I cannot help 
 thinking that the Avant of success depended, as in many of the 
 cases treated by lemon-juice, upon the absence of a sufficiently 
 active converting power in the system. The salt was not 
 assimilated and decomposed, and therefore did not act as an 
 alkali, but accumulated in the system and operated as a purga- 
 tive. This at least is certain, that in the cases alluded to it 
 exercised far less control than usual over the acidity of the 
 secretions, and failed to produce much action as a renal depu- 
 rant. 
 
 The only uncertainty attaching to any of the above stated 
 results, is that arising from the difficulty in arriving at a correct 
 conclusion respecting the quantity of urine passed. In no case 
 can this be ascertained with accuracy, as it is often impossible 
 to catch the urine which is voided at stool by a patient laboring 
 under acute rheumatism. In every instance, however, great 
 care was taken to obtain as close an approximation to the truth 
 as possible. 
 
 In 89 cases, not only was the quantity of urine increased, 
 but its solid constituents, as shown by its increased specific 
 gravity, were also greatly augmented. In 14 of the other 19 
 cases, although the urine increased in quantity, there was only 
 a slight corresponding increase in its specific gravity, and in 5 
 the specific gravity was slightly diminished. This variation in 
 the quantity of the solid matters excreted by the kidneys was 
 attributable, I believe, not to any difierence in the quantity of 
 the morbific matter present in the system, but to the varying 
 activity of the cutaneous and intestinal secretions, whereby it 
 happened that in certain cases a far larger amount of matter 
 was carried ofi" by those channels than could be so got rid of in 
 others.
 
 CHAPTER VI. 
 
 ON THE CAUSES OF RHEUMATIC AFFECTION OF THE HEART. 
 
 My remarks on acute rheumatism have been hitherto con- 
 fined to cases in which pain, redness, and swelling of the joints 
 constitute the only local manifestations of the disease. These 
 external symptoms were long regarded as making up the sum 
 and substance of the complaint, the very existence of its inter- 
 nal complications having been unsought for and undiscovered. 
 But clinical observation and pathological research have now 
 unfolded changes in the internal organs of the deepest import ; 
 they have discovered the important and fearful fact that, 
 accompanying the paroxysm of rheumatic fever, there may be 
 not only articular redness and swelling, but inflammation of 
 the lining and investing membranes of the heart, — inflamma- 
 tion of an organ, the mechanism of which is most easily 
 deranged, and which, when deranged, " lays its own hard con- 
 ditions upon the continuance of a man's life, and almost settles 
 beforehand the manner of his death." ^ 
 
 Inflammation of the heart is now recognized as imparting to 
 acute rheumatism its chief danger and perplexity. Does a 
 patient die during the first violence of the attack ? his death is 
 almost invariably attributable to inflammation of this organ^ 
 Does be apparently recover and resume his wonted avocations ?; 
 he is taught, alas ! at no distant period, that there is yet in^ 
 store for him a frightful amount of suff'ering, a long continu- 
 ance of asthma, palpitation, and dropsy, as the result of his 
 former cardiac affection. 
 
 Such being the dangers, and such the suff'ering attaching to 
 rheumatic cardiac affection, it behooves us to investigate the 
 cause of its occurrence, the class of cases in which it is most 
 
 ' Dr. Latham's "Clinical Medicine," p. 156. 
 10
 
 138 ON THE CAUSES OF 
 
 liable to arise, and the possibility of guarding against its inva- 
 sion. 
 
 The first question which arises is as to the cause of its occur- 
 rence. On what does rheumatic inflammation of the heart 
 depend ? ^ 
 
 It was formerly supposed to be due to metastasis, or, in other 
 words, to the retrocession of the disease from the external parts, 
 and its consequent transfer to the membranes of the heart. 
 But more recent and more extended observation has shown 
 that endocardial or exocardial inflammation may occur as the 
 first, and, for some time, the only local symptom of the disease f 
 that it sometimes precedes, by several days, the access of artic- 
 ular redness and swelling, and that even in cases where it does 
 not take place until after inflammation of the joints has been set 
 up, it is rarely preceded or accompanied by subsidence of the 
 previously existing articular mischief. In other words, it has 
 shown that, in the great majority of cases, no connection can 
 be traced between the two sets of actions, beyond their origin 
 in one common source of mischief — in one poison which excites 
 inflammation now at one spot, now at another ; at one time 
 attacking several joints simultaneously or in succession, and 
 then the investing or lining membranes of the heart ; at 
 
 1 Throughout this chapter I make use of the expressions '•inflammation of 
 the heart" and " cardiac inflammation," as applying indifi"erently to inflamma- 
 tion of the endocardial or exocardial membranes. 
 
 2 Five instances of this sort have fallen under my own observation. In two 
 cases the patient labored under pericarditis two days, in another three days, 
 and in another five days, prior to the appearance of articular inflammation ; 
 while in another, the case recorded at p. 288 of this Treatise, the heart ap- 
 pears to have been attacked seven days before rheumatism manifested itself 
 externally. My colleague. Dr. Wilson, has recorded another very striking 
 case in point, in the " Lancet'' for November. 1844, vol. ii, p. 217. Dr. Dundas, 
 Physician to the Northern Hospital, at Liverpool, has favored me with the par- 
 ticulars of another: one is quoted in Dr. Graves's " Clinical Medicine," ed. 2, 
 vol. ii, p. 160 ; one by Dr. Watson, in his " Practice of Physic," vol. ii, p. 284 : 
 one by Dr. Hope, in his "Treatise on the Heart," ed. 3, p. 178; one bj' Dr. 
 Duncan, in the "Edinburgh Med. and Surgical Journal" for 1816; one by M. 
 Hache, in the -'Archives Gcnerales de Mcdecine," vol. ix, p. 325; and two 
 others by Dr. Taylor, of HuddersBeld, " .Medico-Chir. Trans.," vol. xxviii, p. 
 527. Some interesting remarks on this subject are to be found in the " Edin- 
 burgh Monthly Journal," 3d series, vol. xvi, p. 45 ; and others are recorded in 
 various medical periodicals.
 
 RHEUMATIC AFFECTION OF THE HEART. 139 
 
 another, reversing the order of its attack, and exciting inflam- 
 mation first of the heart and then of the articular structures. 
 Hence, although rheumatic inflammation of the heart may pos- 
 sibly be connected, in some rare instances, with the sudden 
 subsidence of articular inflammation, and the transfer of irrita- 
 tion from the external parts, it must be regarded, in most 
 instances, as a mere coincidence, and as an extension of the 
 local manifestations of the disease. 
 
 I have thought it right to be thus explicit in stating my con- 
 viction as to the true pathology of this disease, because a clear 
 and full understanding on this point is essential to a correct 
 appreciation of many circumstances having an immediate and 
 practical bearing on the questions at issue, namely, the class of 
 cases in which cardiac inflammation is most liable to arise, and 
 the possibility of guarding against its occurrence. If, as I be- 
 lieve, it is annexed to the same pathological condition of the 
 system, and arises from the same cause as inflammation of the 
 joints, it is fair to presume that much important information 
 respecting it may be obtained by a close observation of the 
 circumstances which influence the articular inflammation. If, 
 like the external redness and swelling, this internal inflamma- 
 tion be due to the irritation of a materies morbi present in the 
 blood, and circulating with it to every part of the body, then 
 we may infer that those causes which determine the access of 
 inflammatory action about the joints, and which modify its 
 course, will, in this case also, exert a controlling or modifying 
 power. 
 
 What, then, are the facts with regard to the articular inflam- 
 mation ? 
 
 It occurs most frequently and most extensively in cases 
 remarkable for the severity of their general symptoms ; in which, 
 therefore, there is great abundance of the materies morbi, or a 
 state of system peculiarly susceptible of its influence. It does 
 not attack all the joints indiscriminately, but selects diff'ercnt 
 joints in diff'erent cases ; those which are most used, or which 
 have been the seat of injury or irritation, being more than or- 
 dinarily liable to its invasion. It attacks a larger number of
 
 140 ON THE CAUSES OF 
 
 joints, and is more likely to invade any particular joint, in 
 proportion as the local symptoms are more migratory ; and 
 lastly, it may be in great measure prevented and subdued by 
 the use of alkaline and opiate fomentations, and by the exhi- 
 bition of medicines which serve to counteract the rheumatic 
 poison, to promote its elimination, and to prevent its further 
 formation.^ Hence it appears that cardiac inflammation should 
 occur most frequently in cases characterized by great febrile 
 disturbance, and by the number and intensity of the articular 
 inflammations ; that as in most attacks of acute rheumatism 
 some joints usually escape unscathed, so also the heart should 
 sometimes remain unaffected throughout; that it should be most 
 liable to be attacked when the local symptoms of the disease 
 are shifting or migratory, and when, either from some consti- 
 tutional peculiarity or from extraneous and temporary causes, 
 its irritability is unusually exalted ; and that it should be pro- 
 tected by the exhibition of such medicines as are calculated to 
 exercise a sedative influence over it, to counteract or destroy 
 the irritant property of the rheumatic element, and to promote 
 its elimination from the system. 
 
 Some diff'erence of opinion has been expressed as to the ex- 
 istence of any peculiar proneness to heart disease among the 
 severer examples of acute rheumatism, and no less authorities 
 than Dr. Latham and Dr. Watson have stated that "pericar- 
 ditis is not more to be looked for when the disease (rheumatism) 
 is severe than when it is mild." If, by this assertion, they 
 mean that pericarditis is not invariably an accompaniment of 
 severe articular rheumatism, and occurs not unfrequently when 
 the articular symptoms are slight, or altogether absent, I en- 
 tirely concur in their opinion. But it is quite inconsistent 
 with my observation to believe that it often occurs in cases 
 which are not characterized by active symptoms of disease. 
 Whenever I have met with it, even though the articular inflam- 
 mation may have been slight or evanescent, the febrile disturb- 
 ance has always been severe, and accompanied by profuse and 
 sour-smelling perspiration. As many as 114 out of the 130 
 1 For illustrations of this fact, see Cap. V, pp. 119-13G of this Treatise.
 
 RHEUMATIC AFFECTION OF THE HEART. 141 
 
 cases of recent heart affection observed among the rheumatic 
 patients admitted into St. George's Hospital during the time I 
 held the office of Registrar, occurred in the acute form of the 
 disease ; and taking pericarditis alone, 39 cases were noted 
 among the class of acute rheumatism, and 2 only among the 
 subacute ; the number of patients in the respective classes 
 being 246 and 133. In other words, these cases show that 
 whereas pericarditis occurs once in about every 6*3 patients 
 suffering from acute rheumatism, it does not accompany above 
 one in every Q'o-b cases of the subacute form. Nor is the result 
 of my experience inconsistent with that of other observers. 
 Among 114 cases of articular rheumatism recorded by M. 
 Bouillaud, there were 74 of great or medium intensity, and 40 of 
 a slighter description ; and among the first there occurred 64 
 in which the existence of pericarditis or endocarditis was certain, 
 and 3 in which it was doubtful, while among the 40 of the 
 second class its existence was only once discovered.^ Dr. 
 Macleod, without giving any statistics on the subject, says, very 
 decidedly, " according to ray experience, the heart affection is 
 more frequent in severe than in mild cases of rheumatism."^ 
 Dr. Copland is of the same opinion.^ Dr. Wm. Budd believes 
 " that rheumatic inflammation of the heart is most common in 
 severe cases, especially when there is much fever, and the parts 
 affected are numerous ;"^ and Dr. Barclay, my successor as Medi- 
 cal Registrar at St. George's Hospital, states that, " until 
 very recently, he had never seen inflammation of the heart 
 commence in the subacute form of the disease."^ 
 
 Every fact, then, in regard to rheumatic inflammation of the 
 heart is strictly in accordance with what we are led by analogy 
 to expect. In many instances the heart remains unaffected 
 throughout the attack ; and though it does sometimes suffer, 
 even in the milder cases, it is most commonly damaged in those 
 instances which are marked by unusual severity of their gen- 
 
 1 " Traite Cliniqne du Rheumatisme," Preface, p. 12. 
 
 2 On '' Rheumatism," p. 45. 
 
 ^ "Medical Dictionary," vol. ii, p. 195. 
 * "Library of Medicine," vol. v, p. 199. 
 5 " Med.-Chir. Trans.," vol. xxxv, note, p. 14.
 
 142 
 
 ox THE CAUSES OF 
 
 era! symptoms, by the number and intensity of the articular 
 inflammations, and by the rapidity and frequency of their 
 migration. 
 
 So far the analogy is complete. The next question to be 
 decided is, in what cases and under what circumstances the 
 heart's irritability is greatest, and whether it is in such that 
 the risk of inflammation in that organ is most imminent ? 
 
 Experience and observation have long since supplied abund- 
 ant data for a solution of this problem. It is notorious that 
 in youth the heart's action is not only quicker than in more 
 advanced life, biit is also much more readily accelerated. In 
 women, in like manner, the heart is acted on more readily than 
 in men, or, in other words, is more irritable, and more easily 
 excited. In those persons, again, who have been weakened by 
 illness, or by large and repeated bleedings,^ and in those pecu- 
 liar states of system Avhich are marked bj' a deficiency of red 
 globules in the blood, the heart's irritability is much increased, 
 and palpitation is readily induced. These, then, are the cases, 
 theoretically at least, in which cardiac inflammation should be 
 most liable to arise. And so in practice they are found to be. 
 It is now generally admitted that inflammation of the heart is 
 a much more frequent concomitant of acute rheumatism, when 
 occurring in youth, than when occurring in those more advanced 
 in years.- Statistical observations have shown that it is more 
 
 ^ The experiments of Jlessrs. Andral and Gavarret, recorded in the " Annales 
 de Chimie,'' vol. Ixxv, prove most conclusively that bleeding diminishes the 
 number of corpuscles to a remarkable extent, and in that respect brings the 
 blood into a condition resembling the blood in anaemia, in which the heart is 
 peculiarly irritable. Three of these experiments give the following results: 
 
 Amount of glo- "| Case i. 
 bules in 1,000 I " ii. 
 parts of blood j " iii. 
 
 1st Bleeding. 
 
 2d Bleeding. 
 
 3d Bleeding. 
 
 4th Bleeding. 
 
 114-8 
 12.^-3 
 IL'S-V 
 
 111-0 
 124-9 
 120-7 
 
 102-8 
 121-4 
 112-8 
 
 88 7 
 
 99 6 
 
 101 
 
 Messrs. Becqucrel and Rodier also sum up the result of their experiments by 
 stating " the effect of venesection is to cause a great diminution of the corpus- 
 cles, while it only slightly lessens the amount of albumen." (Simon's ■' Chem- 
 istry," vol. i, p. 2.-)0.) 
 
 - Dr. Watson, Dr. Macleod, Dr. Todd, and others bear witness to this im- 
 portant and significant fact.
 
 RHEUMATIC AFFECTION OF THE HEART. 143 
 
 common in women than in men ;• and I have always been struck, 
 both in private practice and in the wards of St. George's Hos- 
 pital, by the frequency of its occurrence in the pale and weakly, 
 in those who have been reduced by previous illness or exhausted 
 by the treatment adopted, and, ca'teris paribus, in those in whom 
 the heart's action is particularly accelerated. Indeed, I believe 
 that after carefully weighing these several circumstances, after 
 considering the age and temperament of the patient, his pre- 
 vious condition, the violence of the attack, the state of the 
 pulse, and the plan of treatment about to be adopted, it is 
 possible to predict, with tolerable certainty, the occurrence or 
 non-occurrence of cardiac inflammation. 
 
 It would appear, then, that whenever the heart's irritability 
 is great, the rheumatic poison must be peculiarly prone to 
 attack that organ on the same principle as it is to invade a 
 joint which has been previously strained, or is constantly used ; 
 and, therefore, that anything which tends to augment the 
 heart's irritability, must tend, pro tanto, to render the patient 
 liable to heart affection ; while anything having an opposite 
 tendency must serve, in some measure, to shield him from such 
 a complication. Hence, although a moderate venesection may 
 be necessary sometimes for the relief of local symptoms, and 
 for the purpose of facilitating the action of remedies, yet 
 excessive bleeding, by inducing irritability of the heart, cannot 
 fail to predispose to cardiac affection ; excessive purgation must, 
 for the same cause, have a similar effect, and so must every- 
 thing which has a like tendency. On the other hand, alkalies, 
 freely administered, by correcting the morbid condition of the 
 blood, and promoting the elimination of the materies morbi, 
 directly tend to obviate inflammation by removing its cause, 
 while with opium, colchicum, and other medicines, they exert 
 a sedative influence over the heart, and thus, in some measure, 
 protect it from danger. 
 
 In thus enunciating my views on the subject under consid- 
 
 1 See Cap. ix, of this Treatise, pp. 280-4.
 
 144 ON THE CAUSES OF 
 
 eration, I liave purposely avoided discussing the oft-mooted 
 question, as to whether a proneness to inflammation of the 
 heart may. or may not, be induced by venesection. A dis- 
 cussion of this sort cannot be decided by reference to any 
 moderate number of cases, and but little if any good can result 
 from an inquiry based upon uncertain and questionable grounds. 
 I have, therefore, contented myself with pointing out those 
 facts -which have appeared to me most interesting and sugges- 
 tive ; and it need only be stated, that by applying the infer- 
 ences from these facts to practice, results have been obtained 
 far exceeding in importance my most sanguine expectations. 
 Not only has the pain been subdued, and the course of the artic- 
 ular inflammation arrested with unusual certainty and rapidity, 
 but in almost every instance the accession of inflammation of 
 the heart has been prevented. 
 
 The treatment which has proved most eflBcicnt for this pur- 
 pose is that which is directed against the pathological condi- 
 tion of the system, out of which arises the tendency to inflam- 
 mation, whether of the heart, the joints, or other parts of the 
 body ; which aims at neutralizing or counteracting the irritant 
 property of the rheumatic poison, at promoting its elimination 
 and preventing its further formation ; and which, at the same 
 time, keeps steadily in view the possibility of aflfording protec- 
 tion to the heart by a strict avoidance of everything likely to 
 increase its irritability, and by the administration of such 
 medicines as are calculated to exercise a sedative influence over 
 it. Among 168 patients whom I have treated for rheumatic 
 fever since I first adopted this plan of treatment, inflammation, 
 whether of the pericardium or endocardium, has occurred in 
 only 31 instances, and in 26 at least, of these, the heart was 
 aff'ected before the patient came under my care. In 2 of the 
 other 5 cases, an exocardial murmur, which was not discovered 
 when I first saw the patient, was distinctly heard on the second 
 day, and may possibly have existed in an incipient state, though 
 it escaped detection, on the first day of treatment ; in 2 others, 
 an endocardial murmur was first noticed on the second day of
 
 RHEUMATIC AFFECTION OF THE HEART. 145 
 
 treatment, and in the other, which is the case detailed at p. 286, 
 an endocardial murmur manifested itself on the third day of 
 treatment. In that case, however, I had only seen the patient 
 once before the commencement of the cardiac mischief, and I 
 had reason to believe the medicine had not been taken regu- 
 larly. In no other instance did cardiac inflammation arise 
 after the second day of treatment, or, in other words, afterthe 
 patient had been forty-eight hours under the influence of the 
 remedies. 
 
 Inflammation, however, is not the only form of disease from 
 which the heart is apt to suffer in rheumatism. Every one who 
 has watched the post-mortem examinations at any of our large 
 public hospitals, must have remarked the close connection sub- 
 sisting between rheumatism and the formation of fibrinous 
 vegetations on the valves and on the lining membrane of the 
 heart. By common consent this cardiac aff"ection has been 
 ascribed to endocardial inflammation, and its presence has been 
 cited as conclusive evidence of the existence of endocarditis at 
 some former period. Observation, however, has led me to take 
 a different view of the matter, and to consider that these fibrin- 
 ous deposits, though common accompaniments of rheumatic 
 endocarditis, are, nevertheless, essentially independent of endo- 
 cardial inflammation, and may and do take place without its 
 concurrence. 
 
 The grounds on which this opinion is based may be briefly 
 stated. Foremost among them is the frequent occurrence of 
 valvular murmurs, dependent on organic mischief, in cases 
 which do not present any symptoms of true cardiac inflamma- 
 tion. Thus, frequently during the active stage of rheumatism, 
 and sometimes during recovery from the disease, while the 
 tongue is cleaning, and the various symptoms are gradually 
 subsiding, a valvular murmur commences, increases steadily, 
 and persists after the patient's recovery. That in many of 
 these cases the murmur is not attributable to inflammation, 
 properly so called, seems indicated by the absence of those 
 general and local signs of inflammation which are usually found
 
 146 ON THE CAUSES OF 
 
 to accompany endocarditis ;^ that it is caused by organic mis- 
 chief, is often rendered probable by the position of the sound, 
 which is clearly traced to the mitral orifice, and is proved by its 
 persistence long after all symptoms of rheumatism have passed 
 away; and that, in some instances at least, it is due to the 
 deposit of fibrin on the valves, independently of active valvular 
 inflammation, is manifest from the result of post-mortem exami- 
 nation. Indeed, I have myself met with two cases in which the 
 valves, though neither red, swollen, nor thickened, — though 
 not presenting any trace, however faint, of true inflammation, 
 were yet loaded with a crop of recent fibrinous vegetations.^ 
 On the other hand, it is certain that, in some instances at least, 
 no unusual eff'ects result from endocarditis, for I have seen 
 three examples of that disease, marked during life by all the 
 ordinary local and general symptoms of inflammation, and 
 exhibiting, after death, unmistakable evidences of inflamma- 
 tory action, such as minute capillary injection, with a swollen 
 condition of the valves and efi'usion of lymph on their surface, 
 in two of which there was no trace whatever of fibrinous 
 deposits, and in the third of which the slightest possible amount 
 of deposit existed in the shape of small beads along the edges 
 of contact of the valves. Dr. Ormerod has also recently 
 quoted a case, related by Dr. Kirkes, of true rheumatic endo- 
 carditis, in which the valves were distinctly swollen and vascu- 
 lar, and yet were unincumbered by fibrinous growths.^ He 
 has also favored me with the particulars of another, in which 
 a similar condition was observed. As then, at one time, recent 
 
 1 That endocarditis may be, and is sometimes unaccompanied by pain, and 
 by other of the ordinary symptoms of inflammation, is admitted, but it is utterly 
 inconsistent with our knowledge of the effects of inflammation in other parts 
 of the body, to suppose that endocarditis is unattended by active symptoms of 
 inflammation, so frequently as the valvular murmurs wliich arise in the course 
 of acute rheumatism would, if always referable to inflammation, lead us to 
 suppose, 
 
 ^ One of these was a case of pericarditis and pleurisy, which proved fatal on 
 the third day after the commencement of the valvular murmur; and one was a 
 case of old-standing heart disease, which proved suddenly fatal, about a week 
 after the commencement of a systolic aortic murmur. 
 
 3 "Gulstonian Lectures" for 1851, p. 29.
 
 KHEUMATIC AFFECTION OF THE HEART. 147 
 
 fibrinous vegetations are found in great luxuriance on valves 
 which present no traces of inflammatory action, and at another, 
 extensive valvular inflammation is seen to exist without the 
 concurrence of such lesions, the conclusion seems forced upon 
 us, that valvular inflammation and fibrinous accretions, though 
 often coexistent phenomena, are yet essentially independent of 
 one another. Indeed, Dr. Hope's experiments on the ass have 
 shown that fibrinous vegetations are not necessarily connected 
 with inflammation at the spot where their formation is observed ; 
 and Mr. Simon's more recent experiments not only lead to the 
 same conclusion, but render it highly probable that their occur- 
 rence is connected with hyperfibrinization of the blood. ^ Yet 
 further, the recent and very valuable observations of Dr. 
 Richardson^ leave little room for doubt that the absence of a 
 due quantity of ammonia in the blood will of itself lead to a 
 separation of the fibrinous element without the concurrence of 
 local inflammation. Thus again we are directed to simple 
 deposition from the circulating fluid in explanation of the phe- 
 nomena in question. Nor does such an occurrence appear 
 improbable, when we consider the close relationship of the 
 endocardium and the blood ; for what supposition can be more 
 reasonable than that some change may be efl'ected in the blood 
 in immediate contact with the irritated membrane, and that 
 fibrin may be deposited in consequence ? If under any circum- 
 stances the deposition of fibrin be possible, what can be more 
 likely than that such a deposit should take place in acute rheu- 
 matism when the blood is surcharged with the material in 
 question, and when, from the extreme acidity of the system, it 
 is in a state ill calculated to hold it in solution ? 
 
 That these fibrinous deposits are connected with some 
 abnormal condition of the circulating fluid seems indicated by 
 a fact I have long remarked, namely, that they are almost 
 entirely confined to cases accompanied by acute and wide- 
 spreading inflammation, and by other circumstances which are 
 not only productive of unusual quantities of fibrin in the blood, 
 
 ^ "Lectures on General Pathology," by John Simon. London, 1850. 
 2 See the Astley Cooper Prize Essay for 185(j.
 
 148 
 
 ON THE CAUSES OF 
 
 but probably impair its solubility.^ And since it has been 
 proved by direct experiment that when a tendency to the 
 deposit of fibrin exists, the fibrinous accretions are most apt to 
 occur on anything projecting into the arterial current ; and 
 further, that they are especially prone to beset those spots 
 
 1 During the time I held the office of Medical Registrar at St. George's Hos- 
 pital, I observed that although every other form of valvular disease occurred 
 not unfrequentlj- without any previous or concurrent inflammation, yet that 
 no deposit of fibrin was ever fouud, except where there either was or had been 
 rheumatism, or some extensive inflammation, which equally with rheumatic 
 inflammation implies an abnormal condition of the blood, and is calculated to 
 increase the quantity, if not to impair the solubility of the fibrin. From the 
 statistics which have been since published by my friend Dr. Barclay, who 
 succeeded me as Medical Registrar of the hospital, ('' Medico-Chir. Trans.,'' 
 vol. xxxi,) a further confirmation of my views may be deduced, for in every 
 instance in which fibrinous deposits were found on the valves there either ex- 
 isted or had previously existed some such mischief. This will be seen on ref- 
 erence to the subjoined facts. Out of 7.") cases of valvular disease examined 
 after death at St. George's Hospital, 21 were instances of fibrinous deposits. 
 The historv of these 21. cases is as follows : 
 
 Recent Rheumatic Fever. 
 Old Rheumatic Fever 
 
 RecentPcricarditis, Pleurisy, and Pneu- 
 monia. 
 Recent Pleurisy, and adhesions resulting 
 from a former attack of Pleurisy. 
 
 3. I " " Recent Pericarditis. 
 
 4. \ " " Pneumonia. 
 
 5. / " " Recent Pericarditis, and adhesions result- 
 ing from a former atfiick of Pericarditis. 
 
 Recent Pericarditis, Pleurisy and Pneu- 
 monia. 
 
 7. I " " Recent Pericarditis and Pleurisy. 
 
 8. I " " Old adhesions resulting from former attacks 
 
 of Pleurisy and Pericarditis. 
 
 9. \ " " Pneumonia, and adhesions resulting from 
 
 former Pleurisy and Pericarditis. 
 
 10. / Rheumatic Fever, doubtful. Pneumonia and Inflammation of the 
 \ Brain. 
 
 11. / " " Pneumonia and recent Pericarditis. 
 
 12. / " " Adhesions, the result of a former at- 
 \ tack of Pleurisy. 
 
 13. / No mention of Rheumatic Fever. Adhesions, the result of a former 
 j attack of Pleurisj-. Diseased 
 \ Kidneys. 
 
 14. ( " " Recent Pericarditis, Pleurisy and 
 y Pneumonia, and adhesions, the 
 I result of former Pericarditis. 
 \ Mottled Kidneys.
 
 RHEUMATIC AFFECTION OF THE HEART. 149 
 
 •where irritation has been excited,^ we cannot be surprised that 
 they shoukl take place on the valves in which, from the very 
 nature of the case, the effects of irritation are most likely to 
 be felt. Indeed, the correctness of this interpretation is attested 
 by their almost invariable occurrence on that side of the valve 
 against which the current of the blood is directed ; as, for 
 instance, on the auricular surface of the mitral valve and the 
 ventricular surface of the aortic valves, as also by the fact that 
 they most abound, if indeed they be not confined, as they some- 
 times are, to the angular projections and the edges of contact 
 of the valves, which are the parts most subjected to tension 
 and pressure. If endocarditis be set up during the existence 
 of a state of blood characterized, as the blood in acute rheu- 
 matism is, by the presence of unusual quantities of fibrin, the 
 deposit of that material at the seat of inflammation is an event 
 in the highest degree probable ; and even if there be no endo- 
 cardial inflammation, the formation of such a deposit on the 
 strained and excited valvular apparatus can hardly be regarded 
 as improbable.^ 
 
 15. / No Rheumatic Fever. Pneumonia. 
 
 16. / " " Recent Pleurisy, -with excessive congestion 
 I of the Lungs, and adhesions, the result 
 I - of former Pleurisy. Diseased Kidneys. 
 
 17. \ " " Recent Pericarditis. Diseased Kidneys. 
 
 18. I " « Pneumonia, and adhesions resulting from 
 / former attacks of Pleurisy and Peri- 
 \ carditis. Diseased Kidneys. 
 
 19' 1 " " Recent Pleurisy, and adhesions resulting 
 
 / from a former attack of Pleurisy. 
 
 20. I '< " Recent Pericarditis. 
 
 21. I " " Adhesions resulting from a former attack 
 \ of Pleurisy. 
 
 1 See the account of Dr. Hope's experiments on the ass. 
 
 2 Dr. Ormerod considers these growths to be the offspring of inflammation, 
 but he is obliged to admit that " deposition from the blood is a process which 
 may, and very often does take place ; and as any roughness on the surface of 
 a valve would be likely to attrac fibrin from the passing blood, even in a 
 healthy individual, such an event might yet more readily ensue in a case 
 where the blood has already a strong tendency to deposit fibrin. Such is the 
 case in acute rheumatism, as appears not only from the analysis of the blood, 
 but from the large inflammatory exudation into the pericardium or pleura, 
 which occurs coincidently in some such cases." ("Gulstonian Lectures " for 
 1851, p. 30.)
 
 150 ON THE ckuSES OF 
 
 A further confirmation of the opinion I have advanced is 
 derived from the extraordinary difference in the frequency with 
 which inflammation of the lungs accompanies the various forms 
 of rheumatic heart affection. Thus, in rheumatism compli- 
 cated by endocardial affection only, inflammation of the lungs 
 or their membranous envelopes has occurred once in every ten 
 cases, whereas it has been observed in rather more than half 
 the cases attended by pericarditis, and in rather more than 
 two-thirds of those marked by endo-pericarditis.^ The pulmon- 
 ary inflammation is certainly due to the same cause of irrita- 
 tion as the cardiac inflammation, and the inflammation on the 
 internal surface of the heart to the same as that on the external. 
 If, then, the organic valvular murmurs be in all cases referable 
 to endocardial inflammation, the difference in the frequency 
 with which pericarditis and endocarditis are respectively ac- 
 companied by inflammation of the lungs, does not admit of 
 satisfactory explanation. Whereas, if my view as to the origin 
 of these murmurs be correct, and the valvular mischief be in 
 many cases occasioned by the deposition of fibrin occurring 
 independently of active endocardial inflammation, the apparent 
 inconsistency is at once explained. And it is rendered proba- 
 ble that the variation observed in the proportion which pul- 
 monary inflammation bears to the different classes of heart 
 affections, may serve to indicate, with tolerable accuracy, the 
 frequency with which valvular mischief arising in the course of 
 rheumatism is referable to other cases than true endocardial 
 inflammation. 
 
 By some persons, the frequent coincidence of pericarditis 
 and inflammation of the lungs or their investing membrane has 
 been referred to the close proximity of the inflamed parts, 
 inflammatory action having a tendency to spread by contiguity 
 of structure. But many years' observation in the dead-house 
 of St. George's Hospital has taught me to attach very little 
 weight to such a supposition, and has induced me to believe 
 that as inflammation, when affecting the lungs, very rarely 
 spreads to the pericardium, so inflammation of the investing 
 * For full particulars on this subject, see p. 283, of this Treatise.
 
 RHEUMATIC AFFECTION OF THE HEART. 151 
 
 membrane of the heart has very little tendency to spread 
 either to the endocardium or to the lungs, and that when such 
 an action is set up in either or both of such parts coincidentlj 
 ■with or during the progress of pericarditis, it is usually caused 
 by the same agency which induced the original attack of in- 
 flammation.^ 
 
 It has been argued that if these fibrinous growths were in- 
 deed the products of simple deposition on the lining membrane 
 of the valves, they would be easily separable from the subja- 
 cent tissues. That in most recent cases they are readily sepa- 
 rable from the subjacent tissues must be admitted, and I can 
 assert, from repeated personal observation, that in some 
 instances, at least, of older standing, the fibrinous band which 
 results under such circumstances can be detached without any 
 damage to the valve beyond that of separating from it its lining 
 membrane. And this amount of cohesion does not necessarily 
 imply antecedent inflammation, inasmuch as fibrin deposited 
 from the blood may obviously after a time become agglutinated 
 to the endocardium so firmly as to cause this amount of mis- 
 chief. 
 
 1 The following statistical record of 2G5 cases of recent pneumonia, pleurisy, 
 or pleuro-i)neumonia, which occurred in St. Bartholomew's Hospital, and with 
 which I have been favored by my friend Dr. Ormerod, of Brighton, confirms 
 the result of my experience at St. George's. The 265 were thus distributed : 
 117 had pneumonia alone, of whom 19 or 1 in 6-1 had pericarditis. 
 86 had pleurisy alone, " 6 or 1 in 14-3 " 
 
 62 had pleuropneumonia, " 8 or 1 in 77 " 
 
 Thus of 
 
 2^- f cases of recent pulmonary ) oo i ' q- I were complicated by 
 I inflammation . . . j [ pericarditis. 
 
 Now, as inflammation must certainly have as great a tendency to spread 
 from the lungs to the heart, as from the heart to the lungs, it would appear 
 that the inflammation of the lungs which accompanies rheumatic pericarditis 
 cannot be regarded as resulting from the spread of pericardiac inflammation 
 in more than one in every eight cases, a proportion which would not interfere 
 materially with the results from which my inferences are drawn. Even this 
 proportion, however, is far higher than that in which there is reason to believe 
 such a spread of inflammation does actually take place, for many of the 33 
 cases of pericarditis in the table were doubtless referable to the same cause 
 which produced the pulmonary affection, and were in no degree attributable 
 to the spread of inflammation, in consequence of the contiguity of the parts.
 
 152 ON THE CAUSES OF 
 
 But the structures which constitute the valvular apparatus are 
 sometimes firmly matted together, and such a condition undoubt- 
 edly points to some antecedent thickening process, probably of 
 an inflammatory nature. Its existence, therefore, in the ma- 
 jority of these cases, is very important and suggestive. In 
 some instances the thickening is, doubtless, referable to an 
 attack of active lymph-effusing inflammation, and the fibrinous 
 deposits take place on the valves partly as a result of the 
 irritation so excited. But the valvular thickening and the 
 deposition of fibrin are not necessarily coincident phenomena ; 
 on the contrary, there appear strong grounds for believing that 
 although thickening of the valves may be, and is sometimes, 
 the result of an active lymph-effusing inflammation, occurring 
 before or coincidently with the deposition of fibrin, yet that 
 not unfrequently it takes place subsequently to the deposit of 
 fibrin, and probably, in great measure, in consequence of it. 
 In many instances in which I have had an opportunity of 
 examining the condition of the valves shortly after the appear- 
 ance of these fibrinous growths, there has been little, if any, 
 thickening of the substance of the valve ; whereas, when the 
 examination has not taken place until these deposits have 
 existed for some time, some thickening or matting together of 
 the structures has been the rule rather than the exception ; as 
 if the presence of these abnormal deposits on the surface of the 
 valve is apt to give rise to irritation and gradual thickening of 
 the contiguous parts. 
 
 If, then, it be admitted that fibrin may be, and is, under 
 certain circumstances, deposited from the blood without the 
 coexistence of endocarditis, it is obvious tliat if we would pre- 
 serve the heart from mischief, it is necessary not only to take 
 precautions against inflammation, but to maintain, at all haz- 
 ards, the solubility of the fibrin. For both these purposes, 
 alkalies and the neutral salts, if freely administered, prove 
 most efficient agents. By counteracting or destroying the 
 irritant property of the materies morbi, and by promoting its 
 elimination, they tend to prevent articular and other local 
 inflammations ; they thus prevent any further augmentation in
 
 RHEUMATIC AFFECTION OF THE HEART. 153 
 
 the quantity of fibrin;^ and by increasing as they do the 
 solubility of that matei'ial, they prove excellent preservatives 
 against its deposition on the valves. 
 
 My views, then, in regard to the occurrence of rheumatic 
 inflammation of the heart, may be briefly stated thus : Its 
 frequency is probably referable to the similarity in structure 
 between the joints and the investing and lining membranes of 
 the heart, the rheumatic poison having a special affinity for the 
 fibrous and fibro-serous textures throughout the bod}^ and fix- 
 ing more particularly upon those which are in any way subjected 
 to irritation." The occurrence of carditis, in any particular 
 instance, is determined, in great measure, by the irritability 
 of the heart, from whatever cause arising ; but according to the 
 intensity of the febrile disturbance, so, cseteris paribus, is the 
 liability to inflammation, whether of the joints, the heart, or 
 any other part of the body, inasmuch as the violence of the 
 febrile symptoms forms a tolerably accurate measure of the 
 amount of the poison present in the system, and of the patient's 
 susceptibility of its influence. The number and intensity of the 
 articular inflammations, and the proneness they exhibit to shift 
 their quarters, serve also as guides to the probability of heart or 
 other internal afiections, not only as indicating the presence 
 of a large amount of morbific matter, and a peculiar suscepti- 
 bility of its irritation, but as showing that it has no special 
 tendency to become fixed to any particular spot, and may, 
 therefore, seize upon the heart, or some other internal organ 
 for which it has more or less affinity. Lastly, the extreme 
 
 1 The experiments of Messrs. Andral and Gavarret have proved that the 
 increase of fibrin in the blood of rheumatic patients is commensurate with the 
 extent and intensity of the local inflammations, and that the quantity of fibrin 
 returns to its normal standard soon after the local inflammations have been 
 subdued. 
 
 '^ " In the heart, as in the large articular structures, the fiber which rheumatic 
 inflammation most affects is always in a relation of compulsory movement with 
 the muscle of which it forms a part. By systole of the ventricle it suffers con- 
 tinual attrition in the pericardium, and in the cardiac valves maintains its 
 office by strain, and with a pull. On the other hand, the dura mater and peri- 
 osteum, which no muscular action is able to displace, are (in great measure) 
 exempted from the local inflammation of rheumatic fever." Dr. Wilson " On 
 the true Character of Acute Rheumatism," " Lancet" for 1844, vol. ii, p. 217.) 
 11
 
 154 ON THE CAUSES OF 
 
 liability to cardiac inflammation, engendered by the repression 
 or rapid subsidence of the articular inflammation, is explicable 
 by the greater quantity of the poison which is thus suddenly 
 thrown into the blood's current. 
 
 Respecting fibrinous deposition on the valves, the following 
 is the view I have been led to adopt : It is due to the presence 
 of an unusual quantity of fibrin in the blood, and to the weak 
 state of solution in which it is held, probably in consequence 
 of the extreme acidity of the system and the absence of a due 
 quantity of ammonia in the blood :' it is essentially independent 
 of valvular inflammation, and may or may not occur coinci- 
 dently with it ; the probability of its occurrence, however, is 
 greatly increased by the existence of active valvular inflam- 
 mation, inasmuch as the slightest roughness or unevenness on 
 a valve, such as would be likely to arise from inflammation, 
 would form a nucleus for a deposit of fibrin, and would thereby 
 favor the tendency to its deposition. Moreover, its occurrence 
 must be rendered probable by the existence of active articular 
 inflammation, inasmuch as such inflammation not only produces 
 a vast augmentation in the quantity of fibrin, but implies an 
 extremely acid state of the system in which the fibrin is held 
 in very weak solution. It takes place on the valves in prefer- 
 ence to other parts of the heart, partly in consequence of the 
 extreme susceptibility to the irritation of the rheumatic poison 
 exhibited by the fibrous tissue which enters into their compo- 
 sition ; partly in consequence of the excited state in which they 
 are kept by their unusually frequent and forcible contact with 
 each other, and by the passage over them and impulse against 
 them of blood which has become abnormally irritating in its 
 character ; partly, and also in consequence of the strong tend- 
 ency which exists to the deposition of fibrin on anything pro- 
 jecting into the arterial current." A further consideration of 
 the circumstances under which these accretions take place, 
 serves also to explain why the angular projections and the 
 
 1 See Dr. Rickardson's " Aslley Cooper Prize Essay" for 1856. 
 
 2 See report of Mr. Simon's experiments in his " Lectures on General Pa- 
 thology."
 
 RHEUMATIC AFFECTION OF THE HEART. 155 
 
 edges of contact of the valves are frequently loaded with fibrin- 
 ous deposits, while the surface and free edges of the valves, 
 and other parts of the endocardial membrane, retain their 
 healthy, unincumbered condition. For nothing can be more 
 certain than that fibrinous deposition may be determined to a 
 spot by any cause calculated to roughen or irritate the endo- 
 cardial membrane : and the angular projections and the edges 
 of contact of the valves are just the* parts which are most sub- 
 jected to tension, attrition, and pressure.
 
 CHAPTER VII. 
 
 ON RHEUMATIC INFLAMMATION OF THE HEART. 
 
 In the preceding chapter I have endeavored to trace the 
 predisposing cause of rheumatic carditis : in the present, I 
 propose to commence by a description of the organic changes 
 to which it gives rise, and afterward to proceed to the expo- 
 sition of its physical signs and general symptoms. By follow- 
 ing this course, the latter will he more readily understood and 
 appreciated, as they will thus he recognized as the natural 
 results of the local changes induced in the heart and its mem- 
 branes, and of the altered mechanism consequent thereupon. 
 
 It has been already stated, that when in the course of acute 
 rheumatism the heart becomes the seat of inflammatory action, 
 its investing and lining membranes, the pericardium and the 
 endocardium, are both apt to be implicated in the mischief 
 which takes place. Pericarditis, however, is occasionally met 
 with, uncomplicated by any other affection of the heart ; and 
 endocarditis, in like manner, may run its course without the 
 concurrence of inflammation of the pericardium. Under these 
 different circumstances lesions are produced, which differ widely 
 in their seat and character, and 1 will therefore first describe 
 the changes produced by an attack of pericarditis, and then 
 proceed to those resulting from an invasion of endocarditis. 
 It will be necessary, however, to a full understanding of the 
 subject, to take into consideration the nature of the membrane 
 inflamed, and the circumstances under which the inflammation 
 takes place. 
 
 The pericardium is a serous membrane, and partakes of the 
 characters which belong especially to that class of tissues. 
 Its inflammation, therefore, is of the adhesive kind, and is 
 accompanied by an effusion of serum or of plastic lymph, or of
 
 RHEUMATIC INFLAMMATION OF THE HEART. 157 
 
 both these products in varying proportions ; or sometimes, 
 more especially in unhealthy subjects/ by a serous effusion 
 more or less tinged with blood, and mixed with curdy, ill-con- 
 cocted lymph, having a tendency to assume a puriform char- 
 acter. But the pericardium is not only a serous membrane, it 
 is also a shut sac, the two opposed surfaces of which are in con- 
 tact with each other, and kept in constant motion, the one on the 
 other, by the natural action of the heart. Hence, although 
 when it becomes inflamed, the inflammation may be sometimes 
 controlled by judicious treatment, before it has involved the 
 whole extent of the membrane, yet more generally the constant 
 attrition of the two inflamed surfaces keeps up and aggravates 
 the original mischief, until it has spread over the entire surface 
 of the heart. 
 
 The effects which follow an attack of pericarditis vary accord- 
 ing to the extent of the disease and the character of its pro- 
 ducts in each particular instance. When the membrane has 
 been only partially implicated, lymph may be poured out in 
 quantity insufficient to cause adhesion between the two layers 
 of membrane, and then by degrees it may be gradually reab- 
 sorbed until a white patch on the heart only remains where a 
 thick coating of lymph had previously existed ; or it may be 
 effused in larger quantities, and the inflamed surfaces may be 
 glued together at the seat of inflammation ; or serum mixed 
 with only a small quantity of lymph may be effused, distending 
 the sac of the pericardium, and keeping its two surfaces more 
 or less asunder, in which case adhesions take place less readily, 
 and those which do occur are partial and irregular. When the 
 entire membrane becomes inflamed, the changes produced are 
 proportionably extensive. If the effusion consist chiefly of 
 coagulable lymph, the two surfaces may become agglutinated 
 together throughout their whole extent ; if it consist of lymph 
 and serum, the liquid part may be gradually absorbed, and 
 
 1 I say " in unhealthy subjects," because these differences in the products of 
 the same disease are due here, as elsewhere, to differences of constitution, and 
 to circumstances tending to influence the patient's strength ; and the changes 
 which subsequently take place in the morbid products are also governed by 
 such peculiarities.
 
 158 RHEUMATIC INFLAMMATION OF THE HEART, 
 
 universal adhesion may take place as before ; while if it con- 
 sist chiefly of serum mixed with pus, or with shreds of curdy 
 lymph of low vitality, or if the serum be very copious and be 
 not readily absorbed, adhesion sometimes fails to take place, 
 the sac of the pericardium becomes permanently distended, 
 and the heart's action greatly embarrassed. The former results 
 are met with in the vigorous and healthy ; the latter are 
 observed chiefly in the scrofulous, weakly, or unhealthy. In 
 the first class of cases, if the patient survive the first shock of 
 the attack, he may at first experience little ill effects from the 
 lesion his heart has sustained. Indeed, according to my expe- 
 rience, such is generally the case Avhen adhesion occurs between 
 those parts of the pericardium which are naturally in appo- 
 sition ; and even when parts not naturally in apposition have 
 become adherent, a temporary and partial recovery may ensue, 
 and the suff'erer, though tormented by palpitation and dyspnoea 
 on exertion, may yet survive his attack for a period varying 
 from a few months to twelve months, or even to several years. 
 But in the second class of cases there is no effort at recovery, 
 and the unhappy patient lingers on a victim to palpitation and 
 frightful paroxysms of dyspnoea and suff'ocation, until after the 
 lapse of a short time — sometimes in the course of a few days — 
 his life and his suff"erings are terminated rather suddenly by 
 death. 
 
 It has been suggested that the lymph efi"used in pericarditis 
 is often thoroughly reabsorbed, so that the pericardium is 
 restored to the condition of health, and perfect recovery takes 
 place. This I do not believe to be the case. Doubtless it may 
 be reabsorbed to a very great extent, so that a thin layer only 
 may remain where a copious and thick deposit had previously 
 existed, but I quite agree with Dr. Latham and Dr. Watson 
 that adhesion, more or less general, between the two layers of 
 the pericardium, is the most favorable issue we are justified in 
 expecting, when inflammation has been extensively diff"used over 
 the membrane. For although we see and know that the lymph 
 poured out in iritis idsappears, and are bound to admit that 
 there is no, a priori, impossibility in the reabsorption of the
 
 ITS PATHOLOGICAL EFFECTS. 159 
 
 lymph effused in pericarditis, still the improbability is so great 
 as to amount almost to an impossibility. In iritis, the inflamed 
 parts may be kept tolerably at rest, and the inflammation 
 speedily subdued, and as the quantity of lymph exuded is com- 
 paratively small, its absorption may be effected under the influ- 
 ence of mercury before it has time to become organized. But 
 in pericarditis the constant attrition of the two inflamed sur- 
 faces keeps up and aggravates the existing inflammation, so 
 that it endures for a lengthened period ; the lymph is usually 
 poured out in very large quantities, and in healthy persons, 
 when its vitality is great, shows a strong disposition to become 
 organized, and as the two surfaces of membrane, each loaded 
 with a layer of this plastic medium, are constantly in appo- 
 sition, it is difiicult to conceive how they can fail to become 
 adherent. But our post-mortem records show clearly and indis- 
 puial)ly that a small and partial effusion of lymph may some- 
 times accompany pericarditis, and that not unfrequently the 
 lymph is curdy and but slightly plastic. In both these cases 
 adhesions may fail to take place. In the first, because the 
 lymph, even if plastic, is not in quantity sufiicient to restrain 
 the to-and-fro motion of the two surfaces of the membrane. In 
 the last, because it is from its nature but little disposed to form 
 adhesions, and, moreover, is almost invariably accompanied by 
 a copious eff*usion of serum, which keeps the two surfaces of 
 the pericardium asunder, until by continued washing it is ren- 
 dered shreddy, and, for the most part, inapt for the purpose of 
 adhesion. In such cases, doubtless, absorption of the lymph 
 is gradually eff'ected to a very great degree, and some loose 
 membranous bands, or a few white patches only are left, such 
 as have been well described by Mr. Paget, in volume xxiii 
 of the " Medico-Chirurgical Transactions." But inordinary 
 cases, when extensive pericarditis occurs in healthy persons, a 
 large quantity of highly plastic lymph is poured out, and then 
 so rapidly does adhesion take place and organization of the 
 plastic medium commence, that I look upon its complete absorp- 
 tion as next to impossible. 
 
 Thus, then, to speak in general terras, the primary effects
 
 160 RHEUMATIC INFLAMMATION OF THE HEART, 
 
 produced by extensive inflammation of the investing membrane 
 of the heart are — first, off'usion either of lymph or scrum, or of 
 serum mixed with coaguhible lymph, or with curdy, ill-concocted 
 lymph, or with more or less blood or pus : and then either 
 absorption of the liquid, and adhesion of the pericardium to 
 the heart over a greater or less extent, or else a still further 
 continuance of effusion, and death as its natural consequence. 
 It must not be imagined, however, that death occurs only in 
 cases accompanied by an abundant liquid effusion, for although 
 these are generally the most unfavorable instances, yet fatal 
 results are sometimes met with even when little else than lymph 
 has been poured out. Nor does the fatal issue occur at any 
 particular period of the attack ; rarely, indeed, does it take 
 place at a very early date, but it sometimes happens before, 
 sometimes not until after adhesion has taken place. Thus the 
 morbid appearances observed on dissection vary both w-ith the 
 character of the inflammation and with the period at w^hicli the 
 attack has proved fatal. If death has occurred early, traces 
 of inflammation may be often observed even before cutting into 
 the bag of the pericardium. Lymph and serum, and sometimes 
 pus, may be found effused into the anterior mediastinum, while 
 the pericardium itself is distended with fluid, or if not much 
 distended, is soft and pulpy to the touch. And no sooner is 
 its cavity laid open than the reason of this abnormal condition 
 is apparent. In the former cases it will be found to contain 
 an enormous collection of serum, sometimes clear, more often 
 turbid, generally containing flakes of lymph, not unfrequently 
 tinged with blood ; and when this is allowed to escape, the sur- 
 face of the membrane will be seen highly vascular, and covered, 
 over a greater or less extent, by a coating of recent coagulable 
 lymph. In the latter cases a small quantity only of liquid 
 effusion Avill be found, but a large amount of plastic lymph, 
 often tinged or mottled with blood, will be seen deposited in 
 successive layers on the internal surface of the sac. And a 
 very peculiar appearance this lymph presents. The constant 
 motion and attrition of the parts prevent its forming a smooth 
 surface, and its appearance varies according to the amount of
 
 ITS PATHOLOGICAL EFFECTS. 161 
 
 serum present and to the vitality of the more solid exudation. 
 If it be of low vitality, it adheres very loosely to the membrane 
 which exudes it; much of it is detached by the motion of the 
 heart, and floats in loose shreds in the surrounding serum, 
 while that which still remains adherent to the membrane is 
 rough, loose, and shaggy. If it be more highly organizable, 
 and serum be present in sufficient quantity to keep the two 
 sides of the sac asunder, and thus prevent their immediate adhe- 
 sion, then it is thrown, by the action of the heart, into rough and 
 irregular transverse ridges. If, on the other hand, there be 
 little serum present, and the membrane be covered with a thick 
 coating of highly plastic lymph, then is the tendency to adhe- 
 sion great ; very slight lateral motion of the membrane can 
 take place, and a spongy, or honey-comb, or tripe-like appear- 
 ance is produced by the repeated contact and separation of the 
 two inflamed surfaces. 
 
 These are the appearances observed when the patient falls an 
 early victim to the attack ; but when he dies, as he sometimes 
 does, at a later stage of the complaint, soon after the pericar- 
 dium has become adherent to the heart, there are other points 
 worthy of observation. The medium of adhesion will be found 
 to consist of plastic lymph, still soft and easily broken down ; 
 and which, on more than one occasion, I have known to give 
 way during life on the speedy recurrence of pericardial inflam- 
 mation. But in this lymph may be seen here and there some 
 bloody spots or streaks, or anastomosing red lines, the first in- 
 dications of its commencing organization. 
 
 And if a still longer period elapses before death, the organ- 
 ization of the plastic lymph will be found completed, and the 
 pericardium will be seen either firmly and uniformly glued to 
 the heart, or attached to it by bands, or a net-work of fine ad- 
 hesions having a smooth glistening surface, and presenting the 
 characters of serous membrane. 
 
 Such are the eff'ects, such the changes produced by inflamma- 
 tion of the investing membrane of the heart, and inflammation 
 of its internal or lining membrane gives rise to lesions equally 
 striking and disastrous. The natural transparency of the mem-
 
 162 RHEUMATIC INFLAMMATION OF THE HEART, 
 
 brane may be replaced by whiteness and opacity ; fibrin may 
 be deposited upon it, forming beaded or wart-like fleshy excres- 
 cences ; and lymph may be effused either beneath or on its 
 surface, giving rise to thickening, rigidity, and puckering. In 
 some cases I have known ulceration ensue, which has not only 
 produced a perforated condition of the valves, or a broken-down, 
 ragged state of their edges, but in one or two instances, has 
 spread to the chordae tendineae, which have been thus eaten 
 through and rendered useless. Some cases, too, are on record, 
 though I have never met with one, in which suppuration of the 
 muscular substance of the heart has taken place, and has caused 
 perforation of the septum ventriculorum.^ Happily, however, 
 phenomena such as these are seldom the result of rheumatic 
 inflammation ; and when they do occur, they may be regarded 
 as the offspring of a peculiarly unhealthy constitution. 
 
 It sometimes happens that inflammatory products are found 
 in the different chambers of the heart, more especially in the 
 left auricle; but in most instances they are confined to the val- 
 vular apparatus or its immediate neighborhood, and the mitral 
 and aortic valves, the valves which have most fibrous tissue in 
 their composition, and which are constantly bathed in highly- 
 fibrinized arterial blood, are those which appear peculiarly liable 
 to suffer. The right cavities, however, with their tricuspid and 
 pulmonary semilunar valves, are sometimes, though rarely, 
 affected.^ 
 
 The fibrinous vegetations which constitute the most frequent 
 form of rheumatic valvular lesions vary greatly in their appear- 
 ances in different cases and at difterent stages of their existence. 
 They are often very numerous, and vary in size from a pin's 
 head to a millet-seed. They are at one time isolated and dis- 
 tinct from each other, at another partially confluent; and when 
 several spring from a common base, they may form a mass of 
 
 1 For cases in illustration of this fact, see Dr. Watson's ■• Practice of Physic," 
 ed. I, vol. ii, p. 287, and a Report by .Mr. Avery, iu the second volume of the 
 " Trans, of the Pathological Society of London." 
 
 2 For cases in point, see the fifth volume of the "Edinburgh .Medical and 
 Surgical Journal," and the particulars of a case recorded by my colleague, Dr. 
 Wilson, in the "Lancet" for 1844, vol. ii, p. 217.
 
 ITS PATHOLOGICAL EFFECTS. 163 
 
 considerable size. Sometimes, when their growth has been 
 rapid, or, to speak more correctly, when fibrinous accretion has 
 taken place rapidly, as it does under certain conditions of con- 
 stitution, their form is changed, and the action, which in other 
 states of the system might have resulted in the deposition of 
 small warty granules along the edges of contact of the valves, 
 gives rise to the production of long filamentous growths, or of 
 large pedicled masses forming pendulous tumors, which hang 
 loosely into the ventricle, and are moved to and fro by the cur- 
 rent of the blood. ^ When the vegetations assume the former 
 character, they are usually confined to the valves, and chiefly 
 affect their edges of contact, so that in the sigmoid valves they 
 are arranged in a double crescentic form f but when their 
 growth is more luxuriant, as in the instances last alluded to, 
 they are more widely distributed over the endocardial mem- 
 brane. The surface of the valves, against which the current of 
 the blood is directed, is often thickly studded with them ; on 
 the edges of contact of the valves, they form festoons or fringes ; 
 the chordae tendineae attached to the mitral valve are sometimes 
 loaded with an abundant crop of them; and occasionally in the 
 different chambers of the heart, more especially in the left 
 auricle, they are scattered profusely over the entire surface of 
 the lining membrane. Judging from my own experience, the 
 cases in which these last forms of vegetation occur are just 
 those in which, either from some constitutional peculiarity, or 
 from some other cause equally beyond our ken, these accretions 
 manifest a strong tendency to decay, and in which arise those 
 formidable erosions and ulcerations already mentioned as some- 
 times accompanying rheumatic endocarditis.* 
 
 The microscopic examination of these fibrinous deposits es- 
 
 1 Some of these masses, measuring from half an inch to an inch in length, 
 are preserved in the museum of St. George's Hospital. 
 
 2 Dr. Watson's "Lectures," ed. 1, vol. ii, p. 267. 
 
 ^ "In a patient of Dr. Hawkins's, I saw a cylindrical excrescence of this 
 kind, which measured an inch in length. The valves presented slit-like perfo- 
 rations, and from the edge of one of these slits in the mitral valve, this long 
 vegetation dangled into the ventricle. The whole of the valves of the aorta 
 were covered on their ventricular surface with similar but shorter excrescences." 
 (Dr. Watson's "Lectures," ed. 1, vol. ii, p. 25.S.)
 
 164 KHEUMATIC INFLAMMATION OF THE HEART, 
 
 tablishes the itientity in nature of their different forms, and 
 shows that they are sometimes granular, but more generally 
 imperfectly fibrous in texture, presenting somewhat of a lami- 
 nated appearance ; and that throughout their structure are 
 numerous granules and granular masses, and oil-globules in 
 varying proportions. In some instances of old-standing rheu- 
 matic endocarditis, I have seen cartilaginous and calcareous 
 deposits on the valves and in the fibrinous deposits ; but this, 
 doubtless, has resulted from earthy or atheromatous degenera- 
 tion which has taken place subsequently to the attack, in which 
 the valves were injured or the fibrin first deposited. 
 
 In color and consistency these accretions vary just as much 
 as in size and in position. They are sometimes gray and 
 friable, sometimes of a pink or reddish color, soft, and easily 
 broken down, and can be readily detached from the smooth 
 surface of the membrane on which they are deposited ; at 
 others, they are less colored, and of a much firmer consistence, 
 but still admit of being separated from the membrane ; while, 
 in another class of cases, or rather at a more advanced period 
 of the disease, they become perfectly colorless, and so firmly 
 adherent, that they can be removed only by tearing the mem- 
 brane to which they are attached. At a still later period, these 
 warty growths or bead-like accretions cease, in most cases, to 
 exist as such upon the valves ; they become by degrees more 
 firmly agglutinated to the endocardial membrane, and incorpo- 
 rated with the structure of the valve ; and merging gradually 
 into one another, until the divisions between the several 
 granules are efi"aced, they are ultimately replaced by a lami- 
 nated ridge of fibrin. This is marked at first by serratures 
 corresponding to the divisions between the original granules, 
 but after a time it also loses all traces of its origin or mode of 
 formation, and becomes smooth and polished like the rest of the 
 endocardium. 
 
 Such are the changes which ensue when there is a tendency 
 to the repair of these valvular lesions; but when, as is fre- 
 quently the case, there exists a tendency to further disorgani- 
 zation, the changes which occur are of a different character.
 
 ITS PATHOLOGICAL EFFECTS. 165 
 
 The fibrinous deposits appear to excite unusual irritation, and 
 to give rise to thickening of the valves, with gradually induced 
 rigidity, corrugation, and contraction ; the motion of the valves 
 becomes more and more limited, and adhesion of their flaps 
 sometimes ensues ; or, perhaps, earthy or atheromatous degen- 
 eration takes place, and the valvular apparatus, strained by the 
 unwonted force and frequency of the heart's action, and ren- 
 dered weak and brittle by the changes it has undergone, is no 
 longer able to offer resistance, and is lacerated or slit up. 
 
 These changes on the internal surface of the heart, resulting 
 from acute rheumatic inflammation, are far more serious than 
 those produced by inflammation of its external surface. If, in 
 the first fury of its attack, pericarditis be as important and 
 dangerous as endocarditis, it certainly is less so in the lesions 
 it leaves behind it, and in the consequences to which it ulti- 
 mately gives rise. It has been stated that when the former 
 disease is extensively diffused, effusion of lymph and serum 
 takes place which gives rise to adhesions, more or less general, 
 between the visceral and parietal layers of the pericardium. 
 The investing membrane becomes either partially or wholly 
 glued to the heart by the interposed lymph, or loosely attached 
 to it at one or more spots by a single band or a net-work of 
 adhesions. The slightest adhesions must certainly embarrass 
 the heart's action to a greater or less extent, yet when they are 
 partial only, and take place between such parts of the pericar- 
 dium as are naturally in apposition, or when, on the other 
 hand, they are universal, they derange the heart's action far 
 less than might be expected, I have repeatedly, on dissection, 
 seen old lesions such as these in persons who for years before 
 their death had been in excellent health, and during life had 
 exhibited no symptoms of diseased heart. But when the 
 adhesions are formed between those portions of the pericardial 
 sac which are not naturally in apposition, then, unless they be 
 very loose, they cause a drag upon the heart, and restrain the 
 freedom of its action to a much greater degree ;^ palpitation and 
 
 1 Louis has recorded an instructive case in point. A single adhesion had 
 taken place between the parietal pericardium and that portion of the visceral
 
 166 RHEUMATIC INFLAMMATION OP THE HEART, 
 
 dyspnoea ensue, and the organ, struggling to overcome the 
 resistance, becomes gradually more and more dilated and 
 bypertrophied, until, when it is unable any longer to fulfill its 
 functions, the blood begins to be arrested in its passage through 
 the lungs, and cough and dyspnoea and palpitation result. Then 
 follows the terrible array of symptoms connected with an 
 impeded pulmonary circulation : A loading of the capillaries 
 with dark-colored, imperfectly aerated blood, coldness and 
 lividity of the extremities, blueness of the lips and face, con- 
 gestion of the liver and other internal organs, and, as the 
 natural consequence, dropsical effusion into the cavities of the 
 chest, into the abdomen, and into the cellular tissue of the body. 
 Nor do these fearful changes occur without producing a pro- 
 portionate amount of suffering. Excessive palpitation, with 
 prjBcordial pain and anguish ; paroxysms of dyspnoea threat- 
 ening suffocation, orthopnoea, constant restlessness, and impos- 
 sibility of sleep ; — these are among the inevitable consequences 
 of such an embarrassed state of the vascular and respiratory 
 systems, and are the symptoms immediately preceding death. 
 Cases^ however, in which symptoms such as these are dependent 
 solely on exocardial mischief are of rare occurrence, inasmuch 
 as extensive rheumatic pericarditis seldom runs its course 
 without concurrent endocardial inflammation, and even when it 
 does so, rarely produces much hypertrophy of the heart, or gives 
 rise to any marked symptoms of cardiac affection, unless, as 
 already stated, the adhesions which result, whether partial or 
 universal, are formed between those parts of the membrane 
 which are not naturally in apposition. Such at least is the 
 result of my experience ; the only exception being in the case 
 of patients who, from their position in life, have been forced to 
 pursue some laborious occupation.' 
 
 pericardium which invests the right ventricle. The result was, that the patient 
 was unable to lie on his back, inasmuch as, whenever he assumed that posi- 
 tion, the heart at each systole dragged upon the band which held it back, and 
 thereby caused excessive pain and smarting. 
 
 1 I am acquainted with a gentleman, at the present time, who had a severe 
 attack of pericarditis, at the age of ten, followed without doubt by very general 
 adhesion of the pericardium. He is now twenty-nine years of age, and has
 
 ITS PATHOLOGICAL EFFECTS. 167 
 
 But when inflammation of the endocardium has occurred, and 
 any permanent traces of its ravages have been left behind, 
 hypertrophy and dilatation are almost certain to be produced 
 before any lengthened period has elapsed. In this CMse the 
 chief effects of the inflammation are displayed on the valvular 
 apparatus of the heart; and so delicate and so nicely adjusted 
 is this apparatus, that any damage it sustains, however slight, 
 must necessarily interfere with the due maintenance of the 
 circulation. If the valves be not actually broken down by 
 ulceration, or loaded with fringes of fibrinous deposits, they 
 will probably be rendered thicker and more rigid than natural, 
 or will bear on their angles small bead-like or granular accre- 
 tions. In order to overcome the obstacle thus presented to the 
 circulation, the heart will have to contract more forcibly than 
 natural. Thus, if the obstruction be permanent, and the 
 increased labor of the heart continue, hypertrophy of its walls 
 and dilatation of its cavities will be produced, and then, as in 
 the former case, the disease will prove fatal, with palpitation, 
 dyspnoea, and dropsy. Of course, the rapidity with which the 
 disease runs its course will depend, in some measure, upon the 
 irritability of the heart, the state of the lungs, the habits of the 
 patient, and other collateral circumstances, but, eseteris 'paribus, 
 it Avill bear a tolerably constant relation to the amount and 
 nature of the valvular disease. The more serious the mischief, 
 the greater the obstruction to the blood's current, the quicker 
 will hypertrophy and dilatation result, and the sooner will the 
 effects of these lesions be perceived. 
 
 I have hinted that the mischief produced by endocarditis 
 may not be of such a nature as permanently to affect the action 
 
 never yet experienced the slightest heart symptoms. x\s a boj', he took violent 
 and protracted exercise in running, and his heart soon became somewhat 
 hypertrophied and dilated, though not so as to cause him any uneasiness; but 
 from the age of eighteen he has lived a quiet life, and I cannot perceive any 
 alteration in the condition of the heart since that time. Nor do I believe this 
 to be a singular instance. Dr. Wm. Bndd, who has had much experience in 
 these matters, reports that he has " seen a great number of cases of adhesion 
 of the pericardium (often general) of long standing, in which the heart was in 
 all other respects natural, and its functions during life (almost?) perfectly 
 performed." " Library of Medicine," vol. v, p. 195 )
 
 168 RHEUMATIC INFLAMMATION OF THE HEART, 
 
 of the heart, and there is, I think, presumptive evidence to show 
 that some thickening of, or deposit on the valves may take 
 place, and may he entirely got rid of by absorption. Thus, 
 seeing how readily such lesions are repaired in other parts of 
 the body, there can be little doubt but that when the results of 
 endocarditis are confined to redness and oedcmatous swelling, 
 the mischief may subside, and altogether disappear, with the 
 gradual cessation of inflammatory action. Even when lymph 
 has been poured out on the surface or in the substance of the 
 valves, there is reason to believe that it may be gradually re- 
 absorbed, and the damage completely repaired. In most cases, 
 however, we should not be justified in anticipating such a happy 
 result: experience has shown that not unfrequently the process 
 of repair is imperfectly effected, the valves remaining thicker 
 and more rigid than natural. And when, as sometimes hap- 
 pens, the valves are coated with plastic lymph, and become 
 more or less agglutinated together, or one of them, perhaps, is 
 folded on itself, and its apex glued either to the adjoining sui'- 
 face of the aorta or to some other portion of its own area, then 
 the damage which has been sustained is irreparable, and the 
 disease must tend rapidly to a fatal termination. 
 
 But there is another class of cases, in which the question of 
 the possibility and probability of repair does not admit of such 
 a certain answer. I allude to those cases in which fibrinous 
 deposits, more or less extensive, take place upon the valvular 
 apparatus. In extreme instances, doubtless, repair is impos- 
 sible ; but presumption favors the belief that in ordinary cases 
 it is often efiected more or less perfectly. The absorption of 
 the lymph eifused in pericarditis affords a proof that the pro- 
 cesses essential to repair may take place in the heart as in 
 other organs, and the results observed to follow inflammation 
 of other fibrous tissues are conclusive as to there being nothing 
 in the structure of the parts to prevent fibrinous accretions on 
 the valvular apparatus, and the thickening to which they give 
 rise, from being in like manner got rid of, and the parts restored 
 to their former healthy condition. Nay, more than this: dis- 
 section has shown that the jirocess of reparation does sometimes
 
 ITS SYMPTOMS AND PROGRESS. 169 
 
 advance to a considerable extent-/ and observation has proved 
 that functional if not organic repair may, in some instances, be 
 completed.^ But, practically, I fear the cases are few in which 
 this process can be efficiently carried out. When complete 
 reparation is effected in other fibrous structures, it is mainly 
 attributable to the perfect rest at which the parts are kept, and 
 to the mechanical and other local applications we are enabled 
 to make use of; and, even in pericarditis, the injured parts are 
 kept comparatively quiet, by the adhesion of the two opposed 
 layers of the inflamed membrane ; the irritated surface of the 
 membrane can be no longer subjected to attrition ; no more 
 lymph or serum can be poured out, and that which has been 
 already effused may, to a great extent, be got rid of by absorp- 
 tion. But the mischief about the valves takes place under dif- 
 ferent circumstances, and is altogether of a different nature. 
 The fibrinous vegetations which are frequent concomitants of 
 rheumatic endocarditis, and are the lesions from which injury 
 most frequently results, are not the products of inflammatory 
 exudation, but are deposited from the blood, and may and do 
 occur not only during active inflammation, but during a state 
 of mere irritation.^ Hence, as the constant motion of the 
 valves must tend to keep up such a condition, and, as the irri- 
 tability must be further excited by the existence of these 
 adventitious deposits, I fear there is little chance of recovery 
 when obstruction to the circulation is dependent upon this form 
 of lesion. Accurate observation, however, and sound deduction, 
 point out the possibility of such a favorable issue, though ex- 
 perience scarcely holds out any prospect of its occurrence. On 
 three several occasions I have had reason to believe that their 
 removal has been effected partially, if not wholly. In the 
 instances alluded to, the accession of heart disease was marked 
 
 ^ Aniea, p. 164. 
 
 " For some excellent remarks oa this subject, see Dr. Orraerod's " Gulstonian 
 Lectures.'' 
 
 ' This was beautifully exemplified in the course of Dr. Hope's experiments 
 on the ass. As the circulation became sluggish, a deposition of fibrin forming 
 a fleshy vegetation took place at the spot where the heart's valves had beea 
 irritated. 
 
 12
 
 170 RHEUMATIC INFLAMMATION OF THE HEART, 
 
 Ly all the general and physical signs of endocarditis, and the 
 valvular murmur was most intense. Nevertheless, on the rapid 
 subsidence of inflammation, the bellows-murmur gradually 
 ceased. In two of these cases the sound commenced so sud- 
 denly, increased so rapidly, and was accompanied by such 
 well-marked general and local symptoms of carditis, that there 
 could be no more doubt as to the occurrence of inflammation, 
 and of some deposit or thickening as the result of that inflam- 
 mation, than would attach to any fact announced through the 
 stethoscope, but not submitted to ocular demonstration. Doubt- 
 less the murmur in each of these instances is explicable, on the 
 supposition that the valves were merely inflamed and swollen, 
 or that lymph had been eff'used on their surface ; but so con- 
 stantly are fibrinous deposits associated with rheumatic endo- 
 cardial inflammation, that the existence of such deposits in the 
 cases alluded to is rendered extremely probable.^ 
 
 Without pausing to enter more fully into details respecting 
 the changes induced by endocarditis, I will at once pass on to 
 the next part of the subject, and will endeavor to point out the 
 natural connection subsisting between the structural altera- 
 tions caused by exocardial and endocardial inflammation, and 
 the various physical signs by which, during life, we are able to 
 
 1 Three other sources of this adventitious valvular sound might be sug- 
 gestpd: Istly, the an;emic condition of the patient; 2dlj, the increased force 
 of the heart's action, corabineil with some disproportion between the size of 
 its cavities and the orifices of the aorta or pulmonary artery; 3dly, the irre- 
 gular contraction of the structures connected with the valvular apparatus, 
 consequent on the morbidly exciting condition of the blood. Neither of these 
 explanations, however, seems applicable to the murmur, in the cases in ques- 
 tion. For, in the first place, the patients had not been subjected to depletion, 
 neither were they ana-mic, nor was the sound heard in the course of the large 
 vessels, as on such a supposition it ought to have been ; 2dly, there was no 
 evidence of any disproportion between the size of the ventricles and the orifices 
 of the great vessels, and even if there had been, a murmur consequent thereon 
 should have arisen at an earlier period of the attack, when the heart was act- 
 ing quite as rapidly and forcibly ; and, 3dly, had it been due to irregular con- 
 traction of the structures connected with the valves, and not to organic 
 mischief occurring in the valves themselves, it should have evinced some 
 irregularit3', both as to its character and continuance, whereas it remained 
 constant, and of the same character throughout, though increasing steadily in 
 intensity.
 
 ITS SYMPTOMS AND PROGRESS. 171 
 
 detect their existence, and to trace the various steps in their 
 progress. Here, again, to facilitate explanation, I will first 
 suppose inflammation of the investing membrane of the heart 
 to take place, Avithout the concurrence of the endocardial mis- 
 chief, and will then trace the course of an attack of endo- 
 carditis occurring independently of pericardial inflammation. 
 
 Before tliis, however, let us briefly consider the condition 
 of the parts in a state of health. Closely applied to and 
 investing the heart is a membrane, which, on reaching the 
 root of the large vessels, is reflected on itself and forms a close 
 sac. This sac is termed the pericardium. On its internal 
 surface it is lined by a smooth and glistening serous membrane, 
 the two layers of which, in their natural state, glide smoothly 
 and noiselessly over each other, at each successive systole and 
 diastole of the heart. But, in disease, the condition of the 
 parts is changed, and their mechanism altered. As soon as 
 the sac becomes inflamed, and pericarditis, as it is termed, sets 
 in, the smooth and glistening membrane becomes dry, and, 
 after a time, covered by a rough irregular coating of efl'used 
 lymph; its lubricity is consequently destroyed, and its motion, 
 which before was noiseless, is accompanied by the sound of 
 friction, occasioned by the attrition of the two opposed and dry 
 or roughened surfaces. And a very peculiar sound this 
 rubbing sound is. Sometimes it is rough, harsh, and rasping ; 
 sometimes it more nearly resembles the creaking of leather, as 
 it is heard in a new saddle in riding ; but whatever its tone or 
 musical variety, it has the peculiarity of being almost invaria- 
 bly a to-and-fro sound, accompanying the whole of the heart's 
 action, and superadded to its natural sound. ^ From the posi- 
 tion of the parts in which it takes its origin, this sound is 
 superficial, and seems near to the ear, and this, among other 
 
 1 This peculiarity of the sound attendant upon pericardial inflammation was 
 first, I believe, pointed out by Dr. Watson, and about the same time, by Dr. 
 Stokes, of Dublin. To these eminent physicians the profession is indebted for 
 the separation or analysis of the abnormal sounds, arising in the course of 
 cardiac inflammation: in other words, for distinguishing between the friction- 
 sound and the bellows-murmur, and for showing that the former results from 
 exocardial inflammation, the latter from causes connected with the internal 
 surface of the heart.
 
 172 RHEUMATIC INFLAMMATION OF THE HEAKT, 
 
 things, serves to distinguisli it from the double bellows-murmur, 
 which is pathognomonic of valvular disease. Another peculiarity 
 attaches to this sound. Unlike the double murmur of valvular 
 disease, which generally arises from permanent mischief, and 
 is therefore necessarily persistent, the to-and-fro sound of 
 pericardial friction results from causes of a transient nature, 
 and endures, therefore, only for a limited period. It arises, as 
 already shown, from the rubbing of the two roughened layers 
 of the pericardium, and anything Avhich prevents this rubbing 
 must necessarily put a stop to the friction-sound also. Hence 
 it may cease from one of two causes : either from adhesion of 
 the two layers of the membrane by means of interposed lymph, 
 or from their total separation by the effusion of a large 
 quantity of serum. In the former case, the cause of its cessa- 
 tion is a permanent one ; consequently, when adhesion is firm 
 and universal, the friction-sound can never recur ; in the latter, 
 its cessation is due to temporary causes only, and when the 
 serum is reabsorbed, and the inflamed and roughened surfaces 
 come again into apposition, the sound of attrition will probably 
 reappear, to cease only when permanent adhesion has taken 
 place. So that in watching a case of pericarditis, we must not 
 be misled by the subsidence of the friction-sound. If we have 
 once satisfied ourselves as to its existence, we must endeavor 
 to ascertain whether its disappearance be due to excessive 
 effusion, or to adhesion of the two layers of the membrane ; as 
 if due to the former cause, it would be a fatal mistake to 
 slacken in our efforts to arrest the disease, under the idea that 
 adhesion had taken place, and that the disease was progressing 
 to a favorable termination. Fortunately, therefore, the 
 effusion to which I have alluded gives abundant physical signs 
 of its existence. 
 
 The first and natural effect of its occurrence, is the produc- 
 tion of a dull sound on percussion in the praecordial re- 
 gion. In the normal condition the precordial dullness is 
 seldom above an inch and a half or two square inches in extent, 
 as the lung laps over the remainder of the heart, and yields a 
 clear sound on percussion. But when effusion takes place into
 
 ITS SYMPTOMS AND PROGRESS. 173 
 
 the pericardial sac, the space occupied by the heart and its 
 envelope increases, the lungs are pushed aside, and the chest 
 is found to yield a dull sound on percussion, where it had pre- 
 viously furnished a well-marked resonance. Sometimes this 
 dullness is found as high as the second or even the first left 
 rib ; sometimes it extends beneath the whole length of the 
 sternum, except about an inch and a half at the top ; not 
 unfrequently it reaches over to the right side of the sternum, 
 and occasionally I have known it to extend over almost the 
 whole of the anterior surface of the chest. Sometimes, indeed, 
 increased pr?ecordial dullness may be occasioned by old-stand- 
 ing enlargement of the heart ; but in a previously healthy 
 person it is symptomatic of effusion, and affords a tolerably 
 accurate measure of its amount. Its absence, however, must 
 not be regarded as certainly indicative of the absence of 
 effusion, as the dullness which otherwise would have resulted 
 from the presence of effusion, may be masked by the interven- 
 tion of a portion of emphysematous lung. In such a case the 
 chest would yield unusual resonance. 
 
 Thus, then, if the cessation of the friction-sound be dependent 
 on distention of the pericardial sac, percussion will readily 
 indicate the fact; and in proportion as the effusion increases 
 in quantity, so will the limits of the dullness be extended, and 
 so also will the heart's action become more and more embar- 
 rassed, its impulse more feeble and irregular, and its sounds 
 more distant and less audible. This, I need hardly say, is just 
 the reverse of what happens when the friction-sound ceases in 
 consequence of adhesion of the two layers of membrane; for as 
 absorption progresses, and adhesion takes place, the prsccordial 
 dullness decreases in extent, the heart's impulse becomes 
 steadier, its sounds louder and clearer, and the pulse firmer 
 and more regular. 
 
 It may sometimes happen, that we miss listening to the 
 heart until so much fluid has been effused into the pericardium 
 that a friction-sound is no longer audible. In hospital practice 
 patients often are not seen until after the stage of attrition lias 
 passed away ; and even in private practice cases sometimes
 
 174 RHEUMATIC INFLAMMATION OF THE HEART, 
 
 occur, in -v\hicli, either from the rapidity with Avhich effusion 
 has taken phice, or from tlie absence of pain and other general 
 symptoms of cardiac distress, the stage of attrition is entirely 
 overlooked. In some such instances an inclination of the body 
 forward, or firm pressure exerted over the region of the heart, 
 serves to bring the two layers of the pericardium into apposi- 
 tion, and thus enables us to detect exocardial friction. But it 
 sometimes happens that even these measures are ineffectual, 
 and then percussion is peculiarly valuable ; it affords informa- 
 tion not otherwise attainable. I have known prsecordial dull- 
 ness, for days, the only physical sign of the mischief Avhich had 
 occurred, and taken conjointly with the distance, feebleness, 
 and irregularity of the heart's sounds, it has enabled me to 
 trace accurately the extent to which effusion had proceeded. 
 
 There is one other physical sign by which the existence of 
 pericarditis is sometimes marked. • I mean a peculiar fremisse- 
 ment or thrill communicated to the chest, and from the chest 
 to the hand, when placed on the situation of the heart. This 
 strange sensation is most perceptible between the cartilages of 
 the second and third, and the third and fourth ribs on the left 
 side of the chest. Like the friction-sound, it results from a 
 vibration occasioned by the attrition of the two roughened 
 surfaces of the pericardium, and hence it imparts to the touch 
 the same information Avhich is conveyed by the friction-sound 
 to the ear. Its appearance and its disappearance are also 
 regulated by the same circumstances on which the commence- 
 ment and the cessation of the friction-sound depend, but, unlike 
 the friction-sound, it is by no means always, or indeed gen- 
 erally, present. In every case accompanied by this thrill, in 
 which I have had an opportunity of examining the conditions 
 of the parts after death, the outer layer of the pericardium has 
 been found glued, as it Avere, to the parietes of the chest by 
 lymph effused into the anterior mediastinum ; and if, as I 
 believe, this consolidation of the parts, and the consequent 
 formation of a good conducting medium, be essential in peri- 
 carditis to the production of this tremor, then is the unfre- 
 quency of its occurrence at once explained ; as is also the fact,
 
 ITS SYMPTOMS AND PROGRESS. 175 
 
 that it usually accompanies the whole of the heart's action, 
 whereas the purring tremor, communicated to the chest by 
 extensive disease of the valvular apparatus, is usually felt only 
 with the systole of the heart, when that organ is brought into 
 contact with the anterior parietes of the chest, I do not 
 recollect having ever met with this observation in books, but I 
 have already verified it in five instances, and am satisfied of its 
 correctness. 
 
 Accompanying this thrill, in certain cases, is an undulatory 
 movement visible on the chest, in the same position where the 
 friction-thrill is felt, viz., between the cartilages of the second 
 and third, and the third and fourth left ribs. Whenever the 
 eye detects this motion, it is almost certain that the friction- 
 thrill will be sensible to the touch ; but it by no means follows, 
 that when friction can be felt, this undulatory movement will 
 be perceptible on the chest. This, I believe, is attributable 
 solely to the difference in the amount and character of the 
 effusion. For as the undulation is a motion communicated to 
 the parietes of the chest, by the movement of fluid in the peri- 
 cardial sac, it obviously will not, and indeed cannot, be present, 
 when the products of inflammation are chiefly solid. The 
 value of these signs, however, both of friction and of undula- 
 tion, is greatly diminished by the fact, that they do not occur 
 until an advanced period of the attack, when the real character 
 of the disease can hardly be mistaken. 
 
 Thus, then, the first and the only pathognomonic sign of pevi- 
 carditis, is the peculiar sound of friction I have endeavored to 
 describe ; superficial in its situation ; audible, perhaps, over a 
 considerable surface of the chest, but inaudible along the aorta 
 or large vessels ; varjung in its tone according to the nature 
 and amount of the eff"usion, but almost always preserving its 
 distinctive character of a to-and-fro sound, produced by the 
 rubbing of two roughened surfaces upon each other. In any 
 case in which this has once been heard, there cannot be a doubt 
 as to the existence of pericardiac inflammation ; the only ques- 
 tion which can arise, is as to its progress and mode of termina- 
 tion. And here again we derive the greatest assistance from
 
 17G RHEUMATIC INFLAMMATION OF THE HEART, 
 
 a careful study of the physical signs. If the friction-sound 
 cease after a short existence, and coincident with its cessation 
 ■we find decreasing dullness in the praecordial region, increasing 
 steadiness in the heart's action, and clearness and loudness of 
 its sounds, the prognosis must be favorable, inasmuch as it is 
 evident that adhesion is taking place, and that, unless some 
 unforeseen accident occur, the patient will go on rapidly to 
 recovery. If the friction-sound continue for a considerable 
 time, it is evident that no great amount of serum can be present, 
 and that the effused lymph must be of low vitality, with but 
 little disposition to form adhesions. Therefore, although the 
 case may go on slowly to recovery, its termination is doubtful, 
 and our prognosis should be given accordingly. If, again, the 
 friction-sound disappears at an early period of the attack, and 
 at the same time we discover increasing dullness in the cardiac 
 region, and find the heart's impulse becoming gradually weaker 
 and more irregular, its sound more feeble and distant, and the 
 pulse fluctuating or intermittent, then we are made aware that 
 the cessation of the sound is referable to extensive effusion into 
 the sac of the pericardium, whereby the heart is greatly em- 
 barrassed ; and as this is always an unfavorable symptom, our 
 opinion must be very guarded. But even then, if, as we watch 
 the case from day to day, we find these symptoms again de- 
 creasing, and the friction-sound gradually returning, we may 
 feel assured that absorption is taking place, and may venture 
 to speak hopefully of the issue, even though the patient be 
 much exhausted and reduced. 
 
 It must be admitted, then, that the physical signs of peri- 
 carditis are satisfactory, not only as resulting from evident 
 mechanical causes, but as being remarkably distinctive in their 
 character, and enabling us to detect the first commencement of 
 disease. In some, though by no means in all respects, the signs 
 of endocarditis are equally satisfactory. If we know the pre- 
 vious condition of the heart, they enable us to discover, at an 
 early period, the inroad of endocardial inflammation, and to 
 point out with certainty the exact situation where mischief has 
 occurred, and where it is still occurring. Some difliculty, how-
 
 ITS SYMPTOMS AND PllOGRESS. 177 
 
 ever, may arise in discriminating between those murmurs which 
 are referable to organic valvular mischief, and those which take 
 their orisrin in functional disturbance ; and if we are unac- 
 quainted with the previous condition of the heart, it is sometimes 
 almost impossible to say whether a murmur results from exist- 
 ing endocardial inflammation, or from old-standing valvular 
 disease. Unfortunately, too, the accuracy of the information 
 we derive from them affords greater evidence of our skill in 
 diagnosis than it does of our ability in effecting a cure. For 
 although they often give us correct and early intelligence of 
 the inflammatory attack, and indicate the exact spot at which 
 mischief is taking place, we generally prove unsuccessful in 
 arresting its progress until it has produced some permanent 
 lesions. They enable us to hasten to our patient's rescue, and 
 prevent the further inroads of disease, but they too often prove 
 us incapable of repairing the mischief it has already occasioned. 
 The nature of the lesions has been already pointed out. 
 They generally consist of greater or less derangement of the 
 valvular apparatus ; and chiefly, though not invariably, affect 
 the valves on the left side of the heart. There may be either 
 thickening, or puckering, or rigidity of the valves themselves, 
 or fibrinous deposits on their edges or surface, or perforation, 
 or tearing, or breaking down of their substance. In all these 
 cases the current of the blood must be more or less interfered 
 with ; in some the onward current must be obstructed ; in some 
 a reflux of blood must take place through the imperfectly closed 
 opening; and in others, the same lesion may cause obstruction 
 to the onward current, and also permit of regurgitation. In all, 
 however, an eddy must be produced, together with a greater 
 or less decree of vibration ; and the result of such vibration is 
 the production of a sound, or, as it -is often called, a murmur, 
 accompanying the rhythm of the heart. If, when there is much 
 obstruction, the heart's cavities be enlarged, and its muscular 
 walls strong, so that a large current of blood is driven forcibly 
 past the obstruction, the murmur produced is more intense than 
 it would be if the cavity of the ventricles were not dilated, and
 
 178 RHEUMATIC INFLAMMATION OF THE HEART, 
 
 its walls not thickenetr — than it would be if a much smaller 
 amount of blood were to be driven less forcibly past the same 
 obstruction ; and so with every variety of lesion. The character 
 of the sound itself, as well as its intensity, must obviously vary 
 according to the exact nature of the mischief and the relative 
 power and proportion of the obstructing and the propelling 
 forces. Sometimes the sound has been supposed to resemble 
 the noise produced by rasping or sawing, and in some cases it 
 has been thought like the cooing of a pigeon ; but generally it 
 is suggestive of the blowing of a pair of bellows, and hence the 
 sound produced by valvular disease, whatever its character or 
 musical intonation, is usually known by the title of "a bellows- 
 murmur." 
 
 By the commencement of a bellows-sound, then, we are ap- 
 prised of the access of endocardial inflammation ; and by the 
 position of the sound, by the direction in which it is heard, by 
 the time at which it occurs, and by the state of the pulse, we 
 are enabled to judge, with amazing accuracy, of the site of the 
 lesion from which it originates. If the murmur be synchronous 
 with the systole of the heart, it must obviously accompany the 
 egress of h\ood frojn the ventricle, and therefore must be refera- 
 ble either to obstruction at the aortic orifice, or to regurgitation 
 through the mitral valve. ^ If it be contemporaneous with the 
 diastole of the heart, it must accompany the entrance of blood 
 into the ventricle, and therefore must be due either to obstruc- 
 tion at the mitral orifice, or to regurgitation throujih the aortic 
 outlet. But then comes the question as to the means of dis- 
 
 1 Of course, if there be great hypertrophy, the thickness of the muscular 
 structure of the heart serves, in some measure, to deaden the intensity of the 
 murmur, as audible by means of the stethoscope. 
 
 2 In this instance, and indeed throughout. I have referred to valvular dis- 
 ease on the left side of the heart only, as rheumatic affection of the valves of 
 the right cavities is exceedingly rare, and its diagnosis somewhat uncertain. 
 Should it occur, however, it may be generally recognized by the fact that the 
 tricuspid murmur is heard further to the right than the corresponding mitral 
 murmur, and that disease of the pulmonary semilunar valves occasions a mur- 
 mur which is more superficial in its character than a corresponding aortic 
 murmur, and is audible along the track of the pulmonary artery, instead of 
 along the course of the aorta and large vessels.
 
 ITS SYMPTOMS AND PROGRESS. 179 
 
 tinguishing the two systolic murmurs from one another, and of 
 discriminating; between the two diastolic murmurs. How can 
 we refer each to its own particular valve ? Partly, as already 
 stated, by its position, partly by the direction in which it is 
 heard, and partly by the character of the arterial pulse. If a 
 murmur accompanying the systole of the heart be heard more 
 distinctly at the base of that organ, and along the track of the 
 aorta, than it is toward the apex of the heart, then is it due, 
 in all probability, to a vibration caused in the onward current 
 of the blood by obstruction at the aortic outlet of the ventricle; 
 and this is rendered still more probable if the pulse at the wrist 
 be weak. If, as I have several times had occasion to observe, 
 more especially in cases of old-standing rheumatic disease of 
 the heart, the murmur be heard along the track of all the larger 
 vessels; if it be perceptible in the carotids, and, as it sometimes 
 is, in the wrist ; and if accompanying this murmur a thrill be 
 felt, not only over the region of the heart, but even in the 
 radial artery, there cannot any longer be a doubt on the subject, 
 as obstruction in the course of the arterial circulation could 
 alone give rise to such phenomena. If, on the other hand, the 
 murmur be heard at the apex and to the left of the heart more 
 distinctly than at the base of that organ ; and if, accompanying 
 this systolic murmur, there be irregularity in the arterial pulse, 
 and great inequality in its force and fullness, then is the disease 
 situated at the mitral orifice. In this case, as in the last, the 
 murmur is produced by the passage of the blood through the 
 roughened, or the rigid and contracted valvular opening, and 
 the pulse is rendered irregular and unequal by the constant 
 variation in the quantity of the blood which, at each contraction 
 of the ventricle, regurgitates, or makes its way back through 
 the imperfect valves into the left auricle. And as in the last 
 case, so also in this, a vibration is often communicated to the 
 chest, causing a thrill or purring tremor distinctly perceptible 
 to the touch ; a thrill, however, which, unlike that which occurs 
 when there is obstructive disease of the aortic valves, is occa- 
 sioned by a backward, instead of by an onward current of
 
 180 RHEUMATfC INFLAMMATION OF THE HEART, 
 
 blood, and consequently is not transmitted to any extent along 
 the aorta and the various arterial tubes. 
 
 The diagnosis then between the two systolic murmurs is clear 
 and satisfactory, and that between the two diastolic murmurs 
 is equally simple and conclusive. If, which is not very fre- 
 quently the case, the mitral valve be so diseased as to cause 
 sonorous vibration in the blood passing from the left auricle to 
 the left ventricle, then will the murmur be heard most dis- 
 tinctly about the middle of the sternum, and thence toward 
 the apex of the heart ; the pulse, owing to the obstruction, will 
 be small, and, unless either the quantity of blood ejected at 
 each systole of the heart be insufficient to cause the aortic 
 valves to flap distinctly, or their sound be drowned by the 
 adventitious murmur, the natural short smart clack, occasioned 
 by their sudden tension, will be heard superadded to or 
 accompanying the murmur. 
 
 But if the abnormal sound arises from the reflux of blood 
 through defective aortic valves, the signs produced will be very 
 difi'erent. Not only will the sound be loudest from about the 
 middle of the sternum upward toward the base, instead of 
 downward toward the apex, of the heart, but in lieu of being 
 heard together with the natural second sound, it will almost or 
 entirely replace it. Moreover, it will be heard along the course 
 of the aorta, and all the large arterial trunks, and will be 
 accompanied by a most singular and characteristic pulse. This, 
 the pulse of aortic regurgitation, derives its peculiarity from 
 mechanical causes. It is not the weak pulse of aortic obstruc- 
 tion, nor the small pulse of mitral obstruction, nor the unequal 
 and irregular pulse of mitral regurgitation, but in its most 
 marked and most striking form, it is the unsustained pulse of 
 unobstructed arteries. There is, in this case, no impediment 
 to the onward current of the circulation, no lack of blood to fill 
 the vessels, and no deficiency of power to propel it, but from 
 the imperfection of the aortic valves, and the consequent reflux 
 of blood into the ventricle, the prolonged swell, which, at each 
 systole of the heart, is naturally imparted to the blood in the 
 vessels, is not sustained ; the successive waves are, therefore,
 
 ITS SYMPTOMS AND PROGRESS. 181 
 
 short and abrupt, and hence the pulse is jerking, and gives a 
 sensation as if successive balls of blood were being shot sud- 
 denly under the finger. So strong is this reflux, and so strong 
 the jerking to which it gives rise, when it exists in any marked 
 degree, that the motion occasioned by it may be seen even at 
 the wrist, and may be felt in almost any part of the body.^ 
 
 The lesions then produced by rheumatic affections of the 
 heart, when existing in a well-marked and uncomplicated form, 
 admit of easy diagnosis, and may soon be recognized, even by 
 an unpracticed ear. But they are often found more or less 
 commingled, two or more of them occurring in the same case, 
 and thus their diagnosis may be greatly complicated. The 
 pericardium may be inflamed coincidently with inflammation of 
 the mitral valve, and then a deep-seated systolic bellows-mur- 
 mur, resulting from mitral disease, may be heard at the same 
 time that the ear is assailed by the loud superficial to-and-fro 
 sound of friction. Sometimes there is a double bellows-murmur, 
 the one accompanying the systole, and the other the diastole of 
 the heart, and this may be occasioned either by disease of a 
 single valve, or by disease of two separate valves ; either by 
 disease of a single valve, of such a nature as both to cause 
 obstruction and admit of regurgitation, or of two separate 
 valves, the one giving rise to the obstructive, the other to the 
 regurgitant murmur. Thus, not unfrequently a loud systolic 
 aortic murmur coexists with an aortic diastolic murmur, and 
 occasionally a systolic mitral murmur occurs coincidently with 
 an aortic diastolic murmur. Sometimes there is even a greater 
 complication, and a systolic murmur, arising in part from mitral 
 regurgitation, in part from aortic obstruction, is followed by a 
 diastolic murmur, occasioned partly by mitral obstruction, and 
 partly by aortic regurgitation. Difficulty also repeatedly arises 
 
 1 In illustration of this, Dr. Watson details the particulars of a very remark- 
 able case. " The shock of this man's artery," he says, " was plainly to be felt 
 through his clothes, by one's hand laid lightly upon the bend of his arm. His 
 wife told me, that for five years past, this jarring blow had made it uncomfort- 
 able for her to take his arm, when they were walking together. The same kind 
 of jerking impulse was strikingly perceptible in the femoral arteries, and in 
 the carotids." (" Practice of Physic," p. 25G, 1st ed.)
 
 182 RHEUMATIC INFLAMMATION OF THE HEART, 
 
 from the fact that one morbid sound may be so loud and promi- 
 nent as to mask and render almost inaudible another, which, 
 under other circumstances, would have announced, in plain and 
 fearful tones, the existence of disease at some other part. But 
 in all these cases the form or forms of diseases which exist may 
 be discovered, and their combinations pointed out, by careful 
 attention to the rules I have laid down — by careful attention 
 to the character and position of the abnormal sound, to the 
 direction in which, and the time at which, it is heard, and to 
 the state of the arterial pulse. 
 
 Our diagnosis, however, is not, in all cases, so certain or so 
 perfect as could be wished. In practice, many difficulties 
 present themselves which cannot be resolved solely by attention 
 to the sounds themselves. Sometimes, for instance, at the 
 commencement of an attack, it is difficult to determine whether 
 a sound, evidently abnormal, but of an indistinct indefinite 
 character, be referable to endocardial or exocardial mischief, 
 and it is only by the effect of firm pressure in the cardiac region, 
 and by the variation in the character of the sound observed in 
 the course of oft-repeated examinations, conducted while the 
 patient is in different postures, that it is possible to arrive at a 
 correct conclusion. 
 
 So, also, it sometimes happens that an ill-developed indefi- 
 nite sound, having its origin in the heart or its membranes, so 
 closely accompanies the respiratory movements as to make it 
 doubtful whether it may not arise from the lungs or pleurae. 
 Here, again, the position of the sound affords no information, 
 but the question may be set at rest by making the patient hold 
 his breath, when, if it be connected with the respiratory organs, 
 it will instantly cease, but will continue as before if referable to 
 the heart. 
 
 Again, it is frequently doubtful whether an endocardial 
 murmur, arising in the course of acute rheumatism, may not be 
 due to functional causes. The question is one, the decision of 
 which admits not of delay, as on it depends the nature of the 
 treatment, and the well-being of the patient. Here our powers 
 of discernment are taxed to the utmost, for it is only by refer-
 
 ITS SYMPTOMS AND PROGRESS. 183 
 
 ence to the appearance of the patient, the treatment -which has 
 been adopted, the nature of the symptoms by which the acces- 
 sion of murmur has been accompanied, and the position and 
 character of the sound itself, that it is possible to arrive at a 
 sound conclusion. According as the patient is pale and 
 exsanguine ; as the murmur varies with the posture of the 
 patient, and is constantly or only occasionally present ; as it is 
 heard most distinctly at the apex, or at the base of the heart, 
 and in the track of the aorta, or of the pulmonary artery ; as 
 it is soft and blowing, or harsh and rasping ; as it is more or 
 less superficial ; and as its accession has been attended or 
 unattended by pain and dyspnoea, by fluttering or irregularity 
 of the pulse, or by evidence of increased cardiac action, so 
 must be our judgment. No certain rule can be laid down to 
 enable the practitioner to estimate correctly the importance of 
 each indication ; but any one who is cautious, and watchful for 
 the accession of cardiac inflammation, will not fail to give a 
 significant interpretation to prsecordial pain and increased or 
 irregular cardiac action ; while, on the other hand, he will not 
 overestimate the importance of a systolic murmur, if it occurs 
 in a pale and weakly person who has been sweated profusely, 
 or has undergone venesection, more especially if it be unac- 
 companied by pain and by increased or irregular action of the 
 heart, and be heard most distinctly in the track of the pulmo- 
 nary artery. 
 
 Thus by paying careful attention to the circumstances which 
 characterize each case, we may generally arrive at a correct 
 conclusion, and if we are sometimes unable to do as much as 
 might be wished toward arresting the progress of the disease, 
 and repairing the damage it has occasioned, it is at least satis- 
 factory to be able to detect its existence, and to feel that, being 
 aware of its nature, we are in a position to do all that can be 
 done for its alleviation or cure. 
 
 I have hitherto spoken only of the physical signs of rheu- 
 matic carditis, which are those on which we must chiefly rely 
 for the detection of commencing mischief about the heart, but 
 the general symptoms are also of considerable importance by
 
 184 
 
 RHEUMATIC INFLAMMATION OF THE HEART, 
 
 directing!; attention to the seat of inflammation and excitinor 
 alarm for the safety of the patient. As soon as active mischief 
 has commenced, the whole aspect of the patient is rapidly 
 changed,' his countenance, which only a short time before had 
 been calm and tranquil, becomes anxious, and his whole manner 
 and deportment show but too clearly that serious mischief has 
 supervened. Sometimes he is restless, more generally he lies 
 quietly flat on his back, and evinces inability or much disincli- 
 nation to lie on his left side. The breathing, which before had 
 been unafi"ected, becomes hurried and shallow, and often ac- 
 companied by a short dry cough; he complains of uneasiness 
 and oppression at the epigastrium, and of pain in the praecordial 
 region, increased on every attempt at full inspiration, as also 
 by pressure with the fingers in the intercostal spaces, or under 
 the cartilages of the false ribs on the left side. He suffers 
 from palpitation, not unfrequently feels faint, and sometimes 
 experiences a sharp pain, almost resembling a paroxysm of 
 angina, shooting through the chest to the scapula, or upward 
 to the clavicle or the left shoulder. 
 
 These symptoms are usually more marked in cases of peri- 
 carditis than in those in which the endocardium only is affected. 
 Moreover, they are apt to vary according to the nature of the 
 inflammatory products. The more solid the character of the 
 inflammatory exudation, and the smaller the amount of serum 
 poured out, the less constrained is the patient in his posture, 
 the less disposition does he manifest to syncope, and the longer, 
 cceteris paribus, does his pulse retain its force and regularity. 
 On the other hand, the larger the quantity of serum poured 
 out — the more tbe pericardial sac is distended — the greater is 
 his reluctance to move or change his posture, the greater the 
 disposition to fainting, and the more feeble, irregular, or inter- 
 mittent his pulse. Indeed, when the effusion is very great, 
 whatever position he may have assumed, whether on his back 
 
 1 Dr. riope, in noticing this peculiar anxiety of countenance, remarks : "The 
 sardonic expression and peculiar contortion of the features attending the worst 
 cases of pericarditis are occasioned by the sympathy subsisting between the 
 respiratory nerves of the face and those of the heart. An impression is con- 
 veyed to the spinal cord through the pneumogastric nerves, and is reflected to 
 the face through the portio dura."
 
 ITS SYMPTOMS AND PROGRESS. 185 
 
 or on his side, or sitting erect, or leaning forward with his 
 arms upon his knees, so fearful is he of accelerating his heart's 
 action, embarrassed as it is by the amount of liquid, that he 
 cannot be induced to change his posture. 
 
 These symptoms of cardiac inflammation are extremely 
 striking, and might be deemed sufficient of themselves to indi- 
 cate the existence and nature of the mischief; but unfortu- 
 nately they are not very distinctive, nor are they very con- 
 stant in their occurrence. Generally, indeed, when the heart 
 is attacked, some pain, dyspnoea, irregularity of the pulse, or 
 some other indication of existing disease, dra^vs attention to 
 the seat of mischief. But I have repeatedly seen cases in 
 which most acute pericarditis has been set up and has con- 
 tinued for some iiays, without the supervention of any symp- 
 toms likely to direct attention to the action which was going 
 on ; and instances not unfrequently occur in which from first 
 to last such general symptoms are altogether absent.^ There- 
 fore when treating a case of acute rheumatism we must never 
 neglect to make a careful examination of the chest as day by 
 day we watch the progress of the disease. Absence of pain, 
 and other general symptoms of cardiac affection, may serve to 
 mislead the unwary, and to beguile them into the idea that the 
 rheumatism is running its ordinary course ; but the more cau- 
 tious and intelligent practitioner will be aware that the absence 
 of such symptoms affords no guarantee for the safety of his 
 patient, and by repeated daily examination of the heart he will 
 satisfy himself that he is not allowing a frightful disease to run 
 on, unheeded and unchecked, in its career. He will listen for 
 the to-and-fro sound of pericardial friction, and for the bellows- 
 murmur, which announces the commencement of endocardial 
 inflammation, and as soon as his ear shall have given him 
 notice of their existence, either separately or together — nay, 
 even before the sounds are fully formed, if from the occurrence 
 of pain, the acceleration or irregularity of the heart's action, 
 
 ^ Cases such as these, in wliich carditis has been unattended by any local 
 symptoms, are familiar to all practical men, and instances have been placed on 
 record by Drs. Andral, Burrows, Latham,* Stokes, Watson, and others. 
 13
 
 186 RHEUMATIC INFLAMMATION OF THE HEART, 
 
 or from any prolongation or roughness of its sounds, he has 
 reason to suspect the commencement of inflammation — he will 
 at once endeavor to arrest its progress by active and appro- 
 priate treatment. Nor will he rest satisfied with having dis- 
 covered its existence ; he Avill take every means to trace its 
 progress in order that he may be able to apportion his remedies 
 to the exigencies of the case, and speak with some certainty as 
 to the issue. If pericarditis be present he will listen anxiously, 
 day by day, for some increased clearness in the cardiac sounds, 
 and some diminution in the intensity of the friction-sound, or 
 in the extent of area over which it is heard, and, by care- 
 ful percussion in the prascordial region, he will ascertain 
 whether the eff'usion into the pericardial sac be, or be not, in 
 process of absorption. In like manner, if the endocardial 
 membrane be inflamed, he will constantly note the increase or 
 the decrease in the force, frequency, and regularity of the 
 heart's action, and in the intensity of the adventitious bellows- 
 murmur, and according to the information his ear aff"ords him, 
 so in great measure will he vary his treatment, and form a 
 favorable or unfavorable diagnosis. 
 
 I have hitherto made no mention of one peculiar train of 
 phenomena which sometimes accompany rheumatic carditis, 
 because, in the first place, their occurrence is somewhat rare ; 
 and, in the second, they are apt to divert attention from the 
 real seat of mischief, and are, therefore, deserving of especial 
 notice. I allude to phenomena resulting from disturbance of 
 the cerebral functions. It has been already stated that a great 
 alteration is usually observed in the expression of the patient, 
 and that excessive restlessness sometimes supervenes as soon 
 as inflammation of the heart is set up. In some instances, this 
 excitement of the nervous centers proceeds to a very much 
 greater extent. The restlessness and anxiety pass into delirium, 
 into quiet or into low muttering delirium, often attended with 
 stupor ; or, on the other hand, into wild uncontrollable delirium, 
 into the delirium of mania, accompanied sometimes by tetanic 
 spasms or by convulsions, which terminate either in extreme 
 exhaustion or in death by coma. Such cases have been long
 
 ITS SYMPTOMS AND PROGRESS. 187 
 
 recognized by the profession, and instances in point have been 
 placed on record by many accurate and observant physiologists.^ 
 In many respects they are very remarkable. They present all 
 the symptoms usually observed in cases of meningeal or cere- 
 bral inflammation, yet are seldom connected with any struc- 
 tural change within the cranium which can be regarded as 
 indicative of inflammatory action. Sometimes, indeed, on dis- 
 section after death the cerebral veins have been found gorged, 
 and some little serum has been discovered eff"used under the 
 arachnoid, or into the ventricles of the brain, but this has been 
 by no means a constant occurrence, and even had it been so, 
 would only have shown that in this, as in all other forms of 
 violent delirium, the circulation in the brain is apt to be inter- 
 fered with, and serum poured out in consequence. But though 
 in most of these instances there has been no vestige of active 
 mischief within the cranium, it has been generally far other- 
 wise with the heart or its investing membrane. Serum and 
 recent lymph have been found effused into the pericardium, or 
 the endocardial membrane has been inflamed, and recent fibrin- 
 ous vegetations have been scattered irregularly over the sur- 
 face of the left auricle, or deposited, in the shape of fringes, 
 along the edges of the valves. Indeed, so constantly has cere- 
 bral disturbance been associated with mischief about the heart, 
 that many have been inclined to regard delirium, occurring in 
 acute rheumatism, as invariably the result of changes going on 
 in the central organ of the circulation. The coincidence is 
 certainly sufiiciently frequent to render it imperative upon every 
 practitioner to examine most carefully into the condition of his 
 patient's heart, whenever symptoms of flightiness or delirium 
 begin to manifest themselves ; but it must not be concluded, 
 without examination, that the heart is certainly the seat of 
 mischief, for cerebral disturbance does occasionally arise, in 
 acute rheumatism, as a result of cerebral or meningeal inflam- 
 
 ^ In France, by MM. Andral, Bouillaud, and Rostan ; and in this country, by 
 Drs. Abercrombie, R. Bright, Burrows, Davis, Latham, Todd, Watson, and 
 others ; several striiiing cases of this sort are detailed in Cap. X, of this 
 Treatise.
 
 u 
 
 188 RHEUMATIC INFLAMMATION OF THE HEART, 
 
 motion ; more frequently in connection vrith pneumonia or 
 pleuritis ; and sometimes, though rarely, Avithout any local 
 internal inflammation. In these cases, again, the stethoscope 
 affords invaluable assistance, inasmuch as it enables us to ascer- 
 tain with certainty whether there be, or be not, mischief about 
 the heart or lungs. If we fail in detecting mischief in the 
 chest, we must direct our attention to the brain and its envel- 
 opes, while if we discover cardiac or pulmonary inflammation, 
 our aim should be to subdue the morbid action there taking 
 place, in the hope that the cerebral disturbance may be sympa- 
 thetic of the cardiac or pulmonary mischief, and may subside 
 coincidently with its cessation.^ 
 
 In summing up the principal facts deserving of notice in 
 / reference to rheumatic inflammation of the heart, I should say 
 that it is incidental to all the stages of acute rheumatism, 
 occurring sometimes before the commencement of inflammation 
 of the joints, and possibly also, in some rare instances, without 
 the concurrence, from first to last, of any active articular symp- 
 toms: it arises less frequently toward the close of the disease, 
 when tending to a favorable termination, than it does at its 
 beginning or during its progress: it supervenes most frequently 
 in acute attacks of the disease, more especially when inflam- 
 mation attacks many joints, and manifests a disposition to shift 
 its quarters: and it is much more commonly met with in the 
 young than in those more advanced in years; more frequently 
 in the irritable than in those of a phlegmatic temperament; 
 more usually in those in whom the fibrous structures about the 
 joints are chiefly afl'ected, than in those who sufier principally 
 from synovial inflammation. As the general symptoms of its 
 accession are variable and uncertain, and are sometimes alto- 
 gether absent, the physical signs, wliich are very characteristic, 
 should be jealously watched for, the chest being examined daily 
 by the stethoscope and by percussion throughout the progress 
 of the disease. On the first indication of cardiac mischief, 
 active means should be taken to prevent its continuance, and, 
 
 1 For full particulars regarding the cerebral symptoms which occur in con- 
 nection with rheumatism, see Cap. X, of this Treatise.
 
 FATAL CASES. 
 
 189 
 
 throughout its course, the physical signs should be carefully 
 attended to, as affording the only certain evidence as to the 
 action of the remedies and the progress of the disease, whether 
 toward a favorable or unfavorable termination. Cseteris paribus, 
 the prognosis should be more unfavorable in cases accompanied 
 by a copious effusion into the pericardium, with great irregu- 
 larity of the heart's action, than in those in which a smaller 
 quantity of serum is poured out, and the heart is less embar- 
 rassed ; more guarded in those accompanied by much constitu- 
 tional depression than in those marked by tolerance of remedial 
 measures; more cautious when, together with the cardiac 
 inflammation, there coexists inflammation of the lungs or 
 pleura, than when the respiratory organs are unaffected ; and 
 much more unfavorable in cases complicated by cerebral dis- 
 turbance, than in those in which the intellect remains un- 
 clouded. 
 
 The subjoined abstract of sixteen cases of acute rheumatism 
 which proved fatal, in St. George's Hospital, under the care 
 of the physicians, during the six years ending December 31, 
 1850, Avill show the important part which cardiac inflammation 
 ordinarily bears in producing a fatal termination, as also the 
 age and sex of the sufferers, and the general character of the 
 post-mortem appearances.^ 
 
 The ages of the patients were thus distributed; 
 
 Fata] cases, under the age of 15 
 
 " between the ages of . . . 15-20 
 " " " 20-25 
 " " " 25-30 
 
 Total 
 
 Male. 
 
 Female. 
 
 Total. 
 
 1 
 3 
 
 2 
 2 
 
 1 
 4 
 
 1 
 2 
 
 2 
 7 
 3 
 4 
 
 8 
 
 8 
 
 IG 
 
 
 1 In the Post-mortem Register, preserved in the Museum of St. George's 
 Hospital, will be found full particulars of all these cases. The history of those 
 which occurred prior to May, 1848, is reported by myself; of those which 
 occurred subsequently to that date, by Dr. Barclay, who succeeded me as 
 Medical Registrar of the Hospital. The post-mortem appearances are recorded 
 by Mr. Prescott Hewett, Mr. G. D. Pollock, Dr. Ilandlield Jones, Mr. Gray, and 
 Mr. Holl, the successive curators of the Museum.
 
 190 RHEUMATIC INFLAMMATION OF THE HEART, 
 
 The particulars of these cases are given below. One other 
 case, which occurred in the person of a man, set. 27, proved 
 fatal, in the year 1846, but, as no post-mortem examination 
 was made, I have omitted all mention of the symptoms during 
 life. 
 
 History. 
 
 Case I. — Mary Ann Harrison, set. 14. — Xo previous attack 
 of acute rheumatism. 
 
 Ailing thirteen days. Redness and swelling of the joints, 
 and pneumonia, thirteen days before her death. 
 
 Pericarditis and endocarditis, four days. 
 
 Occasional delirium, and choreic twitching of the voluntary 
 muscles, three days. 
 
 Post-mortem Examination. 
 
 The Joints and Sheaths of Tendons were slightly increased 
 in vascularity, and contained a thick, tenacious fluid, in which 
 numerous irregularly granular globules were discovered by the 
 microscope. There were no true pus-globules. 
 
 In the Pericardium was serum, with large quantities of 
 recently eflfused lymph, which here and there had formed 
 slight adhesions between the two layers of the pericardial 
 membrane. 
 
 Tlie Mitral and Aoj'tic Valves were red and swollen, and 
 presented on their surface and edges of contact, recent fibrin- 
 ous vegetations of a pink color. 
 
 The Left Lung was in a state of red hepatization almost 
 throughout. 
 
 The Right Lung was loaded with red, frothy serum, and 
 in one or two parts was passing into the condition of red 
 hepatization. 
 
 The Kidneys, Liver, and other Viscera were healthy.
 
 fatal cases. 191 
 
 History. 
 
 Case II. — Frances Webster, aet. 18. — One previous attack 
 of acute rheumatism three years ago. 
 
 Ailing fifty-one days. Inflammation of the joints, forty-four 
 days before her death. 
 
 Pericarditis and endocarditis, forty-three days. 
 
 Pleurisy and pneumonia, thirty days. 
 
 Slight peritonitis, four (?) days. 
 
 Post-mortem Examination. 
 
 Joints not examined. 
 
 Pericardium universally adherent to the heart by soft, recent 
 adhesions, in which minute anastomosing red lines could here 
 and there be traced. 
 
 3Iitral and Aortic Valves loaded with recent fibrinous 
 vegetations. 
 
 Right Pleural Cavity contained an immense quantity of 
 recent lymph and serum. 
 
 Left Pleural Cavity contained recent lymph and serum, 
 though in a smaller quantity. 
 
 Right Lung inflamed in the lower part ; the remaining por- 
 tions of its structure carnified by pressure. 
 
 Left Lung inflamed ; loaded with red, frothy serum, and in 
 parts hepatized. 
 
 Slight Peritonitis, with recent adhesions between the liver 
 and diaphragm. 
 
 Kidneys, Liver, and other Viscera healthy in structure, but 
 congested. 
 
 History. 
 
 Case III. — Thomas Howship, set. 16. — No previous attack 
 of acute rheumatism. 
 
 Suffering twelve months from an eruption, resembling ich- 
 thyosis, on the legs. 
 
 Redness and swelling of the joints supervened suddenly,
 
 192 RHEUMATIC INFLAMMATION OF THE HEART, 
 
 eleven days before his death, on the rapid subsidence of the 
 cutaneous eruption. For two days before the rheumatism 
 showed itself in the joints, he had alternate vomiting and diar- 
 rhoea, which ceased immediately on the appearance of the 
 articular symptoms. 
 
 Inflammation of the kidneys, five days. Pericarditis, four 
 days. Double pleurisy, four days. 
 
 Occasional delirium and slight opisthotonos, two days. 
 
 Urine contained pus and blood. 
 
 Post-mortem Examination. 
 
 Joints not examined. 
 
 Pericardium excessively injected, and coated with a thick 
 layer of recent lymph, and containing, in its cavity, serum, 
 shreds of lymph, and a small quantity of pus. 
 
 Valves healthy. 
 
 Recent adhesions of the Pleurce at the lower part on either 
 side. 
 
 Lungs congested, but still crepitant. 
 
 Kidneys congested. Mucous membrane of the pelvis, infund- 
 ibula, and calices, inflamed and covered with a large quantity 
 of recently eff"used lymph. 
 
 Liver and other Viscera healthy. 
 
 History. 
 
 Case IV. — James Palmer, set. 27. — One previous attack 
 of acute rheumatism eighteen months ago, and palpitation ever 
 since. 
 
 Rheumatism, with occasional redness and swelling of the 
 joints, two months, for which he was admitted into the 
 hospital. 
 
 Slight papular cutaneous eruption twenty days before death. 
 
 Rigors, with alternate diarrhoea and vomiting, followed by 
 great increase of the rheumatic symptoms, and relief of the 
 sickness and purging, four days. 
 
 Erysipelas of the face, two days. Delirium, one day.
 
 fatal cases. 193 
 
 Post-mortem Examination. 
 
 Joints. — Right knee and left wrist contained a large quantity 
 of viscid fluid mixed with Ijmph and pus. The synovial mem- 
 brane lining these joints was extremely vascular. The sheaths 
 of the tendons at the back of both wrists contained a quantity 
 of thick puriform fluid, but the tendons at the fore part of the 
 joints were healthy. The synovial membrane lining the left 
 knee-joint was somewhat increased in vascularity, and the joint 
 contained a larger quantity of synovia than natural, but the 
 fluid was healthy in appearance. 
 
 Pericardium universally adherent to the heart by old adhe- 
 sions, and adherent also to the anterior parietes of the chest. 
 
 Valves healthy. 
 
 Lungs healthy. 
 
 Kidneys congested, and coarse in structure, but smooth on 
 their surface. 
 
 Liver and other Viscera congested, but healthy in structure. 
 
 History. 
 
 Case V. — Jane Lawes, aet. 16. — Had an attack of acute 
 rheumatism ten weeks ago, followed by irregular rheumatic 
 pains, which have continued ever since. 
 
 Second attack ushered in by rigors, followed by inflammation 
 of the joints, twenty-three days before her death. 
 
 Pericarditis, from seventeen to twenty-three days ? 
 
 Pleurisy, eleven days. 
 
 Post-mortem Examination. 
 
 Joints. — Both knee-joints were examined, but no traces of 
 inflammation were found remaining. 
 
 Pericardium enormously distended by serum tinged with 
 blood, and containing massed of lymph floating in it. The 
 free surfaces of the pericardium were covered by a very thick 
 coating of recent lymph, and had contracted partial adhesions 
 with each other at the posterior surface and at the apex of the 
 heart.
 
 194 RHEUMATIC INFLAMMATION OF THE HEART, 
 
 Endocardium on tlie left side white and opaque, but without 
 vegetations. 
 
 Valves otherwise healthy. 
 
 Right Pleural Cavity obliterated partly by old, partly by 
 recent adhesions. 
 
 Left Pleural Cavity contained a small quantity of recently 
 effused lymph and serum. 
 
 Lungs congested, and the lower lobe of the left one com- 
 pressed by the distended pericardium. 
 
 Kidneys large and congested, but healthy in structure. 
 
 Spleen soft and grumous, with numerous white corpuscles in 
 its structure. 
 
 Otlier Viscera congested, but healthy in structure. 
 
 History. 
 
 Case VI. — Edward Jeynes, set. 27. — No previous attack of 
 acute rheumatism. 
 
 Had scarlatina three months ago, and had never been well 
 since. 
 
 Redness and swelling of the joints supervened six days 
 before death. 
 
 Insensibility and stertorous breathing came on while he was 
 in a vapor bath, and he died in about twenty minutes. 
 
 Post-mortem Examination. 
 
 Joints. — Healthy in appearance. Unusual quantity of syn- 
 ovia in the elbow-joint. 
 
 Cranium. — Membranes healthy. Brain not abnormally con- 
 gested : healthy in structure. Ventricles contained the usual 
 quantity of clear fluid. Veins at the upper surface of the 
 hemispheres were very turgid, and filled with thick, dark, fluid 
 blood. Arteries at the base of the brain quite healthy. 
 
 Pericardium in one part presented increased vascularity, 
 and its cavity contained a small quantity of opaque fluid, in 
 which were floating some small specks of fibrin.
 
 FATAL CASES. 195 
 
 Heart somewhat dilated, and its muscular structure flaccid. 
 Walls of left ventricle thinner than natural. Valves quite 
 healthy. Endocardium deeply blood-stained. Blood fluid, 
 thick and dark colored. 
 
 Lungs congested, discolored, and somewhat emphysematous 
 anteriorly. Otherwise healthy. 
 
 Spleen pale, soft, and pultaceous, and somewhat larger than 
 natural. 
 
 Kidneys and other Viscera healthy. 
 
 History. 
 
 Case VII. — Sarah Woodason, aet. 29. — One previous attack 
 of acute rheumatism ten years ago. 
 
 Frequently suffered from wandering rheumatic pains during 
 the last ten years. 
 
 Long out of health, suff"ering from leucorrhoea and relaxed 
 sore throat. 
 
 Repeated rigors, followed by very severe wandering pains, 
 with profuse acid perspirations twenty-three days before her 
 death. 
 
 Inflammation of the joints eighteen days before her death. 
 
 Profuse perspiration, mercurial diarrhoea. Sloughing of the 
 back and hips. 
 
 Post-mortem Examination. 
 
 Sloughs over both Trochanters, which had burrowed some 
 distance under the integuments. 
 
 Joints. — In the left wrist-joint was a greatly increased quan- 
 tity of synovial fluid, mixed with a small quantity of pus. In 
 the left knee-joint was an increased quantity of synovia, which 
 was thicker and more yellow than natural ; and floating in it 
 were two large pieces of lymph, the largest nearly three inches 
 in length, and a quarter of an inch broad at its greatest 
 diameter. 
 
 Pericardium contained a small quantity of serum, and at
 
 196 RHEUMATIC INFLAMMATION OF THE HEART, 
 
 the base of the left ventricle presented a small spot of ecchy- 
 mosis and some increased vascularity; and at this spot was a 
 small speck of lymph, which could be easily peeled off. 
 
 Valves. — Mitral valve somewhat thickened. Aortic valves 
 healthy. 
 
 Slight recent adhesions of the Pleurce existed at the upper 
 and outer side of the chest on either side. 
 
 Lungs congested, but healthy. 
 
 Kidneys, Liver, and other Viscera healthy. 
 
 History. 
 
 Case. VIII. — George Smith, set. 16. — One previous attack 
 complicated by inflammation of the heart two years ago. 
 
 Present attack commenced with wandering pains in the 
 limbs twenty-one days before his death. 
 
 Increase in the severity of the pains, eighteen days. 
 
 Profuse rheumatic perspiration, but no redness or swelling 
 of the joints. 
 
 Pericarditis, eighteen days. 
 
 Died suddenly. 
 
 Post-mortem Examination. 
 
 Joints not examined. 
 
 Pericardium almost universally adherent to the heart, 
 partly by old adhesions, partly by more recently effused 
 lymph. At the root of the large vessels the lymph was still 
 soft and jelly-like. 
 
 Heart enormously enlarged, and somewhat hypcrtrophied. 
 The cavity of the left ventricle would almost admit the entire 
 hand. 
 
 Valves. — The aortic and mitral valves were both somewhat 
 thickened, and the aortic rather rigid. The tendinous cords 
 of the mitral valve were remarkably developed. 
 
 Lungs congested, but crepitant and healthy. 
 
 The Kidneys, Liver, and other Viscera healthy.
 
 fatal cases. 197 
 
 History. 
 
 Case IX. — Richard Huntley, aat 17. — No history of any 
 previous attack of rheumatism. 
 
 Redness and swelling of the joints commenced twenty-seven 
 days before death. 
 
 Pericarditis between eighteen and twenty-seven days. The 
 exact period uncertain. It existed at the time of his admis- 
 sion into the hospital, when also he was in a state of salivation. 
 
 Endocarditis. Exact period of its commencement uncer- 
 tain. 
 
 Pneumonia about twelve days. 
 
 Pleurisy about five days. 
 
 Larse abscess in the left axilla, stated to have existed from 
 the beginning of the attack. 
 
 Slight delirium previous to death. 
 
 Post-mortem Examination. 
 
 Joints not examined. 
 
 Pericardium contained a large quantity of blood-stained 
 serum. Its free surface was covered throughout b}'- a thick 
 layer of recent lymph, some of which was deeply blood-stained, 
 and some of which was also becoming organized, and pre- 
 sented a vascular appearance. 
 
 Valves. — Mitral more opaque than natural, somewhat 
 swollen, and loaded on the auricular side with recent pink 
 fibrinous deposits. Along the edges of contact, on the ven- 
 tricular surface of the aortic valves, were recent fibrinous 
 vegetations. 
 
 Right Pleural Cavity contained a large quantity of blood- 
 tinged fluid. 
 
 Left Pleural Cavity contained blood-stained fluid, and at 
 its lower part a small quantity of recent lymph, forming a 
 coating to the lung in that situation. 
 
 Rigid Lung gorged with frothy serum, and at is lower and 
 back part were several patches of red hepatization. 
 
 Left Lung was also gorged with frothy red serum, and pre- 
 sented several patches of red hepatization
 
 198 RHEUMATIC INFLAMMATION OF THE HEART, 
 
 The Right Kidney appeared somewhat coarse ; tlie Left, 
 congested, but healthy. 
 
 The Liver, Spleen, and other Viscera congested, but per- 
 fectly healthy in structure. 
 
 History. 
 
 Case. X. — Elizabeth Moore, aet. 20. — No history of any pre- 
 vious attack of acute rheumatism. 
 
 Was confined about nine weeks and a half before her death, 
 and the catamenia appeared once afterward. 
 
 Wandering rheumatic pains five weeks and a half before 
 death. 
 
 Redness and swelling of the joints began twenty-three days 
 before death. 
 
 Pericarditis, sixteen days. Endocarditis, fifteen days ? 
 
 Bronchitis, fifteen days. 
 
 Post-mortem Examination. 
 
 Joints not examined. 
 
 Pericardium much distended by serum, mixed with flakes 
 of lymph ; the whole of its free surface was covered by a 
 thick coating of lymph. 
 
 Valves. — Along the edges of the mitral valves, on the au- 
 ricular surface, was a small fringe of recent fibrinous vegeta- 
 tions ; and the ventricular surface of the aortic valves was 
 slightly coated with recent lymph. 
 
 The Pleurse were partially adherent by old firm adhesions, 
 but presented no trace of recent inflammation. 
 
 The Lungs were loaded with serum and frothy mucus, but 
 were crepitant throughout, and, anteriorly, somewhat emphy- 
 sematous. 
 
 The Kidneys, Liver, and other Abdominal Viscera were 
 congested, but healthy.
 
 fatal cases. 199 
 
 History. 
 
 Case XI. — Elizabeth Adams, set. 30. — No previous attack 
 of acute rheumatism. 
 
 Present illness began, without previous indisposition (?), 
 by redness and swelling of the joints, twelve days before 
 death. 
 
 Pericarditis and endocarditis from nine to five days before 
 death. 
 
 Post-mortem Examination. 
 
 Joints not examined. 
 
 Pericardium contained a small quantity of serum. The 
 membrane itself was highly vascular, and covered by a coat- 
 ing of recently effused lymph. 
 
 Heart. — Tissue flaccid ; under the microscope a large num- 
 ber of oil-globules were detected in its structure. 
 
 Valves. — Aortic healthy. Mitral fringed with recent fibrin- 
 ous vegetations, which extended over both its auricular and 
 ventricular surfaces. 
 
 Pleurse and Lungs healthy. 
 
 Liver much enlarged, and very fatty in appearance. 
 
 Kidneys somewhat coarse in structure and granular on their 
 surface. 
 
 Spleen, Uterus, and other organs congested. 
 
 History. 
 
 Case XII. — Catherine Doyley, set. 17. — Two previous 
 attacks of acute rheumatism. 
 
 " Out of sorts," and suffering from hysteria six days before 
 the commencement of redness and swelling of the joints, which 
 began eighteen days before her death. Inflannuation of the 
 joints only lasted two or three days. 
 
 Pericarditis and endocarditis thirteen days before death. 
 
 Pleurisy five or six days. Sank gradually.
 
 200 rheumatic inflammation of the heart, 
 
 Post-mortem Examination. 
 
 Joints not examined. 
 
 Pericardium. — Thickly covered on its free surface by a 
 coating of recent lymph, which had contracted tolerably firm 
 adhesions, gluing the A'isceral and parietal layers of the mem- 
 brane together throughout their whole extent, excepting on 
 the outer side corresponding to the outer side of tiie right 
 ventricle. 
 
 Heart. — Its cavities dilated and its walls hypertrophied, 
 particularly those of the right side. 
 
 Valves. — Mitral somewhat thickened and covered on its 
 auricular surface, and more particularly along its edges of con- 
 tact, by recent fibrinous vegetations. Similar vegetations were 
 also found on the ventricular side of the aortic valves, along 
 their edges of contact. Valves on the right side healthy. 
 
 Partial old adhesions of the right pleura. 
 
 Rigid Lung infiltrated by frothy serum. 
 
 Partial old adhesions o-f the left pleura, and effusion of 
 serum, and recent lymph at the lower part of the pleural cavity, 
 gluing the lobes of the lung together, and its base to the serous 
 lining of the diaphragm. 
 
 Left Lung infiltrated by frothy serum. 
 
 Kidneys healthy. 
 
 Liver healthy, but its capsule thickened by the effusion of 
 fibrin into its structure. 
 
 Spleen contained numerous deposits of fibrin about the size 
 of a millet-seed. 
 
 History. 
 
 Case XIII. — John Hodges, ret. 21. — No history of any pre- 
 vious attack of acute rhcum'atism. 
 
 Seized with pain in the head, and wandering pains in the 
 limbs eight days before death. 
 
 Redness and swelling of the joints began five days before 
 his death.
 
 FATAL CASES. 201 
 
 Heart symptoms, five days. 
 
 Had a slight fit with ptosis of one eyelid a few hours before 
 death. 
 
 Post-mortem Examination. 
 
 Joints. — Both knee-joints contained a quantity of whitish, 
 opaque, glairy fluid, which appeared under the microscope to 
 be synovia containing a large number of pus-corpuscles. The 
 synovial membrane was highly vascular. 
 
 Pericardium contained about four ounces of an opaque fluid, 
 in which floated numerous shreds of lymph. The free surface 
 was covered by a coating of recent lymph, which, on the 
 anterior surface of the heart, had begun to contract adhesions. 
 The membrane was highly congested, and in one or two spots 
 presented small patches resembling ecchymosis. 
 
 Valves healthy. 
 
 Both Pleural Cavities contained a small quantity of thin, 
 transparent serum. 
 
 Both Lungs were quite healthy and crepitant throughout. 
 
 Kidneys, Liver, and other abdominal organs congested, but 
 healthy. 
 
 A large clot of fibrin, resembling jelly both in appearance 
 and consistence, was found in the cavity of the pelvis. There 
 was no trace of inflammation there. 
 
 History. 
 
 Case XIV. — Ann Amess, set. 21. — Slight rheumatism one 
 year ago, but no previous acute attack. 
 
 Inflammation of the joints seventeen days before death. 
 
 Palpitation and pain in the chest, ten days. 
 
 Miliary eruption of sudamina, seven days. 
 
 Delirium, more or less, three days; violent, twelve hours. 
 
 Post-mortem Examination. 
 
 Joints. — The synovial membrane of both knee-joints was 
 14
 
 202 RHEUMATIC INFLAMMATION OF THE HEART, 
 
 higlily vascular and red. In the cavity of the joints was a 
 cjuantity of turbid, yellow serum, in which floated masses of 
 coagulated lymph, one of which was deeply stained with blood. 
 The cartilages of the joints were clear and white. 
 
 Brain presented nothing remarkable. 
 
 Pericardium contained a small quantity of slightly turbid 
 serum. 
 
 Heart and Valves perfectly healthy. 
 
 Lungs healthy ; a few old adhesions existed in the right 
 pleural cavity. 
 
 Peritoneum contained a small quantity of turbid serum. 
 
 Liver, Kidneys, and other Viscera in the abdominal cavity 
 congested, but healthy. 
 
 History, 
 
 Case XV. — Mark ]\Iindenhall, set. 12. — Several previous 
 attacks of acute rheumatism ; one when he was six years old. 
 Ailing, eighteen days. 
 Inflammation of the joints, fifteen days. 
 Palpitation and endocarditis, at least eleven days. 
 Pericarditis, seven days. 
 Pneumonia. Duration uncertain. 
 Pleurisy. Occasional delirium. Excessive dyspnoea. 
 
 Post-mortem Examination. 
 
 Joints not examined. 
 
 Pericardium contained some serum, and a large quantity of 
 •lymph, which had formed partial slender adhesions over the 
 ventricles. 
 
 Heart somewhat hypertrophied and dilated. 
 
 Valves. — Recent fibiinous vegetations on the mitral and 
 aortic valves. Old thickening of the mitral valve. Slight 
 recent thickening of the tricuspid valve. 
 
 Right Pleural Oavity contained several ounces of serum, 
 mixed with recent lymph.
 
 FATAL CASES. 203 
 
 Lungs congested throughout ; in the lower half on either 
 side inflamed, and in parts in a state of gray hepatization. 
 
 Kidneys, Liver, and other Abdominal Viscera congested, 
 but healthy. 
 
 History. 
 
 Case XVI. — William Davis, aet. 25. — No previous attack 
 of acute rheumatism. Rheumatic symptoms began fourteen 
 days before his death. 
 
 Delirium with much tremor, more or less three days. Furious, 
 one day. 
 
 Pericarditis, a few hours. 
 
 Post-mortem Examination. 
 
 Joints. — Right sterno-clavicular articulation softened, and 
 surrounded by thick, yellow pus. Pus also in the left elbow 
 and in the right ulno-carpal articulation, and extending along 
 the tendons. 
 
 Membranes of the Brain congested. Slight effusion in the 
 subarachnoidean cellular tissue. 
 
 Brain congested. Ventricles filled with serous fluid. 
 
 Pericardium contained a small quantity of turbid serum, 
 and on the surface of the left auricle was a small quantity of 
 plastic lymph. 
 
 Valves perfectly healthy. 
 
 Lungs and Pleurse healthy. 
 
 Kidneys, Liver, and other Abdominal Viscera healthy.
 
 CHAPTER VIII. 
 
 RHEUMATIC INFLAMMATION OF THE HEART, ITS 
 TREATMENT. 
 
 Having traced the causes and described the symptoms of 
 Rheumatic Carditis, it now only remains for me to discuss its 
 treatment. How far is it possible to prevent its occurrence ? 
 How, when it has once commenced, can its course be controlled, 
 or its progress arrested ? How, when its active symptoms have 
 been subdued, can the lesions it has left behind be modified or 
 got rid of? Can we fairly hope to cut short an attack of peri- 
 carditis, to induce absorption of the matters effused, and to 
 prevent adhesion of the two layers of the pericardium ? Or, 
 when inflammation of the endocardium has been set up, can we 
 fairly anticipate a victory over the disease, and a restoration 
 of the .conditions of health ? These are indeed important 
 questions, and demand our full and anxious consideration. 
 
 I have already stated my conviction, that when once peri- 
 carditis or endocarditis has commenced, recovery, in the strict 
 sense of the word, is extremely improbable. There may be 
 apparent recovery ; the patient may so far get well as to 
 resume his ordinary occupations, and, if they be not laborious, 
 he may live for years, without experiencing much ill effect 
 from his attack of rheumatism. But in most cases his subse- 
 quent career will be short, and exceedingly distressing. Before 
 many years have elapsed, he will begin to suffer from asthma 
 and palpitation, as tlie effect of his former cardiac seizure ; and, 
 after death, the hypertrophy and dilatation of the heart, with 
 the whole train of symptoms which have caused his protracted 
 suffering and have terminated in his premature death, will be 
 found to have arisen from disease of the valves, or from adhe- 
 sion of the two layers of the pericardial membrane, the result 
 of the former cardiac inflammation.
 
 RHEUMATIC INFLAMMATION OF THE HEART. 205 
 
 It is obviously, therefore, of the utmost importance to take 
 every precaution against the occurrence of a disease which is 
 followed by such serious consequences. We are bound not 
 only to employ active measures as soon as it has made its ap- 
 pearance, but to use every means which experience has pointed 
 out to guard against its invasion. I will not stop to refer to the 
 influence of particular remedies in exciting or warding off its at- 
 tack, as the whole subject resolves itself into a question respect- 
 ino; the best treatment for the alleviation of rheumatism, and 
 this has been fully discussed in a previous chapter. There is 
 one method of treatment, however, to which has been attributed 
 such especial power in this respect, that I feel bound to make 
 particular allusion to it. I refer to calomel, administered in 
 repeated doses, so as to affect the mouth. 
 
 It has been asserted that, by putting the system under the 
 influence of mercury, it is possible to ward off cardiac inflam- 
 mation. No statement, however, can be more erroneous, or 
 more mischievous : erroneous, because pericarditis is frequently 
 set up while the system is fully under the influence of mercury ; 
 mischievous, because ptyalism forms a grievous addition to the 
 miseries of the disease, very frequently causes excessive 
 depression, and thus tends to give an unhealthy character to 
 the inflammatory products ; and because by its presence we 
 are deprived of a remedy which, administered in due season, 
 and with a proper regard to the exigencies of the case, proves 
 most valuable in promoting those actions whereby the extent 
 of the mischief is limited, and absorption of the inflammatory 
 products induced. Calomel, when given during the progress 
 of inflammation in a healthy person, is assuredly one of our 
 most powerful auxiliaries ; but when given so as to affect the 
 constitution before the commencement of cardiac inflammation, 
 it not only has no influence in preventing the disease, but by 
 the irritability and general depression which it occasions, 
 appears to modify its course in a manner by no means con- 
 ducive to recovery. In five instances I have seen acute peri- 
 carditis supervene at a time when the patient was profusely 
 salivated, and in every case the ptvalism appeared to operate
 
 206 EHEUMATIC INFLAMMATION OF THE HEART, 
 
 prejudicially.^ The inflammation partook but slightly of the 
 adhesive character, the pericardium became enormously dis- 
 tended "with fluid, absorption of this fluid was with difficulty 
 produced, and in two of the cases death was the result. Nor 
 is pericarditis the only complication which I have known 
 occur, in spite of the existence of mercurial action. Endo- 
 carditis and pleurisy have also supervened at a time when the 
 system has been under the full influence of mercury ; and in 
 all such cases the inflammation has run its course as if no mer- 
 curial action had existed. 
 
 But although calomel and opium have no power of prevent- 
 ing the access of cardiac inflammation, those remedies which 
 fulfill the purpose of relieving the general symptoms of the 
 disease, are, to a great degree, safeguards for the heart : what- 
 ever is the best treatment for an uncomplicated attack of acute 
 rheumatism, the same affords the surest guarantee against its 
 various complications. Whether venesection, or guaiacum, or 
 opium be employed, or whetlier colchicum, calomel, alkalies, 
 or purgatives, the heart will be protected from, or exposed to, 
 the risk of inflammation, according as each remedy is admin- 
 istered judiciously. If venesection be employed in the weak 
 and cachectic, or if, even in the strong, it be carried beyond the 
 necessity of the case, it will surely cause irritability of the 
 heart, and favor the extension of inflammation to it. If, on 
 the other hand, it be omitted altogether when vascular action 
 is excessive, when the heart is beating violently and turbu- 
 lently, and secretion is defective or suspended, its omission 
 will as certainly expose the heart to mischief, by leaving it in 
 a state of excitement, which might have been mitigated or sub- 
 dued by the aid of a moderate blood-letting. And so with 
 every remedy which can be named. Its virtue in warding ofi' 
 
 1 •• 1 have never seen more of ragged pulpy deposit on the surface of the 
 heart from recent inflammation of its investing membrane, than in the case of 
 a j'oung woman, who was brought some five or sixj-ears ago into St. George's 
 Hospital, (shortly before her death,) profusely salivated in sequel of rheumatic 
 fever." (•• Observations on the true Character of Acute Rheumatism,'' by Dr. 
 Wilson, Senior Physician to St. George's Hospital. " Lancet" for 1844, vol. 
 ii, p. 254.)
 
 f 
 
 \ 
 
 ITS TREATMENT. 207 
 
 cardiac inflammation varies according to the circumstances 
 under which, and the judgment with wliich, it is employed, and 
 coincides exactly with its virtue in alleviating the general 
 symptoms of the disease. The treatment or the remedy 
 which, under any given conditions of age, temperament, 
 and severity of symptoms, is most effectual in curing the 
 disease, the same is that which will be found most useful in 
 preventing its extension, whether to the heart, the lungs, or 
 any other part of the body. 
 
 Unfortunately, do what we will, we cannot always guard 
 against the access of cardiac inflammation. Oftentimes before 
 we see our patient, inflammation of the heart or its membranes 
 has commenced, and sometimes, even in spite of our efforts, it 
 will supervene while our patient is under treatment. There- 
 fore it becomes necessary to consider, not only how to guard 
 against its invasion, but how to combat its symptoms when 
 once they have commenced. For although, under such cir- 
 cumstances, we can seldom if ever do all we desire for our 
 patient's recovery ; though we can seldom or never prevent 
 his heart sustaining some permanent damage, we may at least, 
 by early and appropriate treatment, do much toward staving 
 off" the final catastrophe. We may arrest the disease in its 
 progress of destruction ; we may lessen the amount of damage 
 inflicted ; and by thus diminishing the impediments to tlie cir- 
 culation, we may greatly defer the day, which sooner or later 
 is certain to arrive, in which the heart, suffering from the effect 
 of successive changes, all resulting from the primary mischief, 
 shall no longer be able to do its work efficiently, and shall thus 
 indirectly prove the efficient cause of asthma, dropsy, suff"oca- 
 tion, and death. 
 
 What, then, are the pathological conditions to be treated, the 
 ends for which means are to be found ? First, there is the 
 morbid condition of the blood ; the primary source of all the 
 mischief. This obviously must be corrected as far as possible. 
 Secondly, there is the local inflammation ; and this must be 
 subdued at all hazards, if we hope to save our patient from 
 immediate death. Thirdly, there are the products of inflam-
 
 208 RHEUMATIC INFLAMMATION OF THE HEART, 
 
 mation ; and these must be got rid of, if we Avish to prolong his 
 days, and to save him from the consequences of a damaged 
 heart. In a previous chapter^ the treatment which is best 
 adapted to fulfill tlic first of these objects, has been fully 
 pointed out ; the second calls for bleeding, and calomel, and 
 opium ; and the third for blisters, diuretics, and a bsorben ts. 
 
 Of all the remedies forthecure of rheumatic inflammation 
 of the heart, venesection is that most generally adopted. M. 
 Bouillaud has employed it very largely in France ; and even 
 here it has numerous and strenuous advocates. Observation, 
 however, has not led me to form a. favorable estimate of its 
 curative power. In some few instances it has been useful in 
 expediting the action of other remedies, and in moderating the 
 force and frequency of the pulse when the patient has been 
 robust, and the heart's action turbulent and excessive. But in 
 general it has afforded very little relief.^ It has usually failed 
 in subduing the pain, and has produced only a temporary im- 
 pression on the pulse. On the other hand, the arguments 
 against its indiscriminate emploj'ment are numerous, practical, 
 and weighty. It certainly is not necessary for the cure of the 
 disease, as I have myself effected many cures without it ; it is 
 not productive of safety to the patient, for M. Bouillaud lost 
 six out of eighteen patients attacked by the disease ; whereas, 
 out of eighty-seven cases, of which I have notes, in which it 
 was not employed, two only proved fatal, one of Avhich was a 
 case of pericarditis, which occurred in a weak debilitated per- 
 son, and was complicated by low quick-spreading inflammation 
 
 1 ChaptPr V. pp. 112-118. 
 
 2 I am glad to quote, in confirmalion of my opinion, the views of those 
 sound practical physicians, Drs. Latham, Todd, and Watson. The former 
 remarks, " my treatment of endocarditis has not been vigorously antiphlogistic. 
 I have seldom employed venesection at all, and never largely," yet, " it has not 
 in a single instance proved fatal under my care ;" whereas, M. Bouillaud's 
 treatment has always been vigorously antiphlogistic ; he has employed large 
 and rei)eated bleedings, "in spite of which, he has had to record numerous 
 instances, in which endocarditis terminated fatally under his management." 
 Dr. Todd, in the same si)irit, says, " my experience leads me to value very 
 lightly the efficacy of general bleeding in inliammation of the heart ;" and Dr- 
 Watson reports, that he '-seldom opens a vein in these cases." 
 
 ;
 
 ITS TREATMENT. 209 
 
 of the pleura. And, lastly, it is often prejudicial to the patient 
 bj exhausting his strength, rendering him liable to relnpses, 
 and altogether protracting his recovery. There also appears 
 strong reason for doubting whether, as suggested by Dr, Wat- 
 son, " bleeding to such an extent as to bring the heart's action 
 to a pause in deliquium," may not tend to favor the deposition 
 of fibrin upon the valvular apparatus. 
 
 General blood-letting then should be employed in rheumatic 
 carditis, under precisely the same circumstances as in cases of 
 acute rheumatism uncomplicated by cardiac inflammation. As 
 a remedy to be exclusively relied upon, it is quite unavailing, 
 and often extremely dangerous : as an expedient to be era- 
 ployed in aid of other remedies, it is occasionally of the 
 greatest service. If a patient be robust and plethoric, with a 
 pulse characterized by extreme fullness or hardness, it may be 
 had recourse to with the greatest advantage, and may be 
 repeated until some impression is produced on the circulation. 
 In such persons it assists in allaying the inflammation, and 
 favors the action of mercury and other remedies. But in 
 ordinary cases its employment is unnecessary, and therefore 
 inexpedient. It tends to diminish the red globules in the 
 blood when they are already below the healthy standard, to 
 render more irritable the already irritable and excited heart, 
 and to favor, as I believe, the formation of fibrinous deposits 
 on the valves. Moreover, if carried beyond the exigencies of 
 the case, it may cause an adhesive inflammation to assume a 
 serous or suppurative character, and may prevent that peculiar 
 and most valuable action of mercury, whereby the extent 
 of inflammation is limited, and its products absorbed and got 
 rid of. 
 
 But although bleeding from the arm is seldom advisable, 
 local blood-letting is often very serviceable. Leeches may be 
 placed over the region of the heart, or blood may be abstracted 
 by cupping, and thus more obvious and more immediate benefit 
 will be obtained, and a greater impression produced on the 
 disease as manifested by the pulse, the stethoscope, and the 
 sensations of the patient, than by the most copious and
 
 210 RHEUMATIC INFLAMMATION OF THE HEART, 
 
 repeated general blood-letting. Not unfrequcntly the precordial 
 pain ceases, the heart's sounds become clearer, and the pulse 
 softer, even while the leeches are doing their work. 
 
 It is sometimes a question whether leeching or cupping is 
 the more appropriate remedy in these cases : and some persons 
 recommend the employment of the former, while others as stren- 
 uously advocate the latter. My own experience inclines me to 
 give a decided preference to leeches. They are quite as easy 
 of application, and are free from the objection very properly 
 urged against cupping, of causing pressure upon the ribs at a 
 spot where, in the inflamed condition of the heart, the least 
 pressure and the least percussion cannot fail to be productive of 
 mischief; and, although this difficulty may be in some meas- 
 ure overcome by applying the cupping-glasses between the left 
 scapula and the vertebral column, I still incline most strongly 
 to leeches ; for 1 have never known cupping produce the same 
 amount of benefit that I have often seen result from leeching. 
 Nor is it difficult to suggest an explanation of the fact. By 
 cupping, blood is often abstracted as copiously, and almost as 
 rapitlly, as by venesection from the arm, whereas leeches do 
 their work more slowly, and by their gradual and continued drain 
 tend perhaps to cause some revulsion from the deeper-seated 
 structures. Be this as it may, they certainly aft'ord an amount 
 of relief out of all proportion to the quantity of blood abstracted 
 through their agency, and incomparably greater in the majority 
 of cases than can be obtained by venesection from the arm, or 
 by cupping as ordinarily practiced. If the force and fullness 
 of the pulse be such as to require blood-letting for its relief, or 
 if the patient be so plethoric as to render it desirable to let 
 blood witii the view of expediting the action of remedies, then 
 bleeding from the arm is the most appropriate treatment. If, 
 on the contrary, the patient be pale and weakly, and the pTBse 
 not more than ordinarily forcible, then, if blood-letting be 
 deemed advisable for the relief of the prsecordial pain and 
 anguish, leeching, and not general bleeding, should be had 
 recourse to. Cupping should be reserved for tliose cases in 
 
 1
 
 ITS TREATMENT. 211 
 
 which a copious bleeding is required, and in which blood does 
 not flow freely from the arm. 
 
 Mercury, like bleeding, is a valuable remedy in rheumatic 
 carditis. Powerfully antiphlogistic in the influence it exerts, 
 it assists in moderating the intensity, and in limiting the 
 extent of inflammatory action ; and having done so, it operates 
 as blood-letting does not, it promotes the absorption of the 
 matters efi"used. Having first of all checked the progress of 
 the disease, it subsequently lends its aid to the process of 
 reparation. 
 
 It is obvious, then, that no case of rheumatic carditis, 
 occurring in a strong and healthy person, can be safely treated 
 without mercury. It may be, and indeed is, generally unneces- 
 sary to have recourse to its antiphlogistic property so long as 
 inflammation is confined to the joints, inasmuch as rheumatic 
 articular inflammation does not ordinarily tend to structural 
 disorganization. But as soon as the heart or its membranes 
 are implicated, the whole complexion of the case is altered. It 
 is no longer a question, then, whether the inflammation may 
 not be resolved without structural mischief ; the mere fact of 
 there being inflammation, implies structural changes of a grave 
 and momentous character, — changes which must be arrested if 
 life is to be preserved, and which, when arrested, must be 
 modified or got rid of if life is to be prolonged. Changes, too, 
 they are, which occur most rapidly, and are slow and difiicult 
 of removal, so that no time must be lost in pressing to its ful- 
 fillment, the treatment considered most efficacious against their 
 extension. For this purpose mercury, of all known remedies, 
 is that on which most reliance can be placed. It does not 
 supersede other remedial agents, but it comes most powerfully 
 and beneficially to their aid. It sustains the good eff"ect pro- 
 duced by blood-letting ; it calms the violence, alters the char- 
 acter, and circumscribes the limits of the local inflammation ; 
 it stimulates the absorbents to the business of repair, and pro- 
 motes the continuance of the natural secretions at a time when 
 they are checked, and well-nigh suspended by the shock the 
 system has sustained.
 
 212 RHEUMATIC INFLAMMATION OF THK HEAHT, 
 
 But to insure these effects the remedy must be pushed until 
 its impression on the constitution is unequivocally declared by 
 the occurrence of ptyalism. Three or four grains of calomel 
 combined with opium, in sufficient quantity to prevent its run- 
 ning off by the bowels, may be given every four hours, and if 
 it be considered desira])le still further to hnsten the access of 
 salivation, mercurial inunction may also be had recourse to. 
 In such a case, a drachm, or a drachm and a half of the strong 
 mercurial ointment may be rubbed in, night and morning, on 
 the abdomen or the inside of the thighs; or a blister may be 
 applied to the region of the heart, and mercurial dressing 
 applied to the blistered surface. Thus, sometimes, in the 
 course of the second, and generally within three or four days, 
 a full mercurial action will be produced. Then, and not until 
 then, have we any guarantee that the medicine has found its 
 way into the system, and that its beneficial influence Avill be 
 displayed. But as soon as salivation has commenced, and 
 even sooner in some instances, the symptoms manifestly im- 
 prove ; the pain and anguish begin to subside, the pulse becomes 
 quieter and steadier, apd the heart's sounds clearer. The 
 cessation of the to-and-fro sound of friction in one case, or in 
 another its recurrence coincidently with the decrease of pme- 
 cordial dullness, denotes the absorption of fluid from the peri- 
 cardium; while, if there be mischief within the heart, the 
 diminished intensity of the endocardial murmur, and the 
 greater regularity of the heart's action, give intelligence of 
 improvement in that quarter. These are facts to which I can 
 testify from repeated observation, and I have so often seen all 
 antiphlogistic remedies employed, and yet no sensible amend- 
 ment produced until after ptyalism has commenced, that I 
 cannot doubt as to the cause of the improvement. 
 
 In this, as in all other serous inflammations, it will sometimes 
 be found difficult to obtain the constitutional effect of mercury. 
 It may be administered freely for a considerable time, and 
 may be guarded carefully by full doses of opium, and yet no 
 mercurial fetor be perceived, no evidence of mercurial action 
 obtained. But it must not, therefore, be inferred that its ex-
 
 1 
 
 ITS TREATMENT. 213 
 
 hibition is useless. As opium, when acting beneficially in 
 delirium tremens, and acute rheumatism, may be given in 
 enormous doses without occasioning either stupor or consti- 
 pation ; so, when the constitution is sound, and inflammation 
 violent and extensive, mercury, while exercising a most bene- 
 ficial influence over the course of the disease, may sometimes 
 prove tardy in producing salivation. It seems as if, under 
 such circumstances, its whole power were expended in allaying 
 the diseased action; and it fairly admits of question, whether 
 the difiiculty experienced in- producing salivation, may not be 
 taken, cseteris paribus, as a test of the extent and activity of 
 the morbid action, and of the necessity for the early and active 
 administration of mercury to control and arrest its course. 
 Certain it is that, in ray experience, the difficulty of inducing 
 salivation has varied, cseteris paribus, according as the patient 
 has been strong and healthy, the inflammatory symptoms 
 unusually high, and the inflammation extensive, and of that 
 peculiar character which tends to the eff'usion of plastic and 
 highly organizable lymph. 
 
 Mercury, though generally beneficial in rheumatic carditis, 
 is not equally so in all constitutions. In robust and habitually 
 healthy persons, it seldom gives rise to much constitutional 
 irritation or depression, and when the inflammation is exten- 
 sive, it produces its specific action slowly, and acts most bene- 
 ficially on the course of the disease. In such cases, therefore, 
 it can hardly be employed too fearlessly or too vigorously. 
 But in the weakly, the irritable, and the unhealthy, its consti- 
 tutional eifects often supervene rapidly, are extremely violent 
 in their character, and, in some instances, frightfully depress- 
 ing, and hence it is productive of injurious consequences by 
 favoring a tendency to serous or suppurative, instead of to 
 adhesive inflammation. To such, therefore, it cannot be ad- 
 ministered too cautiously. In the one set of cases it is essential 
 for the arrest of inflammation at a time when life is threatened 
 by its extreme intensity; and the object being to produce a 
 forcible impression on the disease as rapidly as possible, it can 
 hardly be given too largely or pushed too vigorously. But in
 
 214 RHEUMATIC INFLAMMATION OF THE HEART, 
 
 the other, the system is readily depressed, and when depressed, 
 is prone to set up unhealthy inflammation.^ Therefore, although 
 it may be sometimes deemed expedient to obtain mercurial 
 action in such cases, it is most desirable so to administer the 
 remedy as that the system shall not suffer from its operation. 
 In the first, it should be given in large doses, frequently re- 
 peated in proportion as the inflammation is active, and its 
 progress rapid. In the last, if it be given at all, it should be 
 exhibited in smaller doses, and at longer intervals, and at the 
 least symptom of its action, its administration should be sus- 
 pended. 
 
 Some persons have lately attempted to undervalue the cura- 
 tive influence of mercury in pericarditis,- and others, though 
 not denying its efficacy in many forms of inflammation, have 
 yet contended that the cure of pericarditis, occurring in con- 
 nection with rheumatism, may be safely intrusted to other 
 remedies.^ Now although, as already stated, I do not counsel 
 the indiscriminate employment of mercury, and, in some rare 
 instances, do not administer it even in the most cautious man- 
 ner, yet I cannot accord my assent to a mode of practice which 
 would deprive us of what, in many cases, proves our most 
 powerful ally. Other remedies very often suffice in that form 
 of inflammation which occurs in weakly or cachectic persons ; 
 indeed, the administration of mercury is seldom of much avail 
 in such cases, and is often prejudicial to the patient's safety, 
 especially when the kidneys are diseased. But I am fully 
 persuaded that, in the acute and sthenic form of pericarditis, 
 as it presents itself in persons of a strong and healthy consti- 
 tution, nothing is of greater service than the remedy in question. 
 
 ' This, at least, I can positively assert, that in six cases which have fallen 
 under my observation, in which mercurial action has been accomj'anied by 
 much constitutional depression, the accession of salivation has been marked 
 by the disappearance of the to-and-fro sound of pericardial friction, with coin- 
 cident extension of the priccordial dullness, and increase in the distance and 
 feebleness of the heart's sounds, and that the effusion thus unequivocally 
 declared, has been slowly and with difficulty removed. 
 
 2 See some papers published in the "Medical Times" for 1849, by Dr. John 
 Taylor, of Huddersfield. 
 
 3 See a paper by Dr. J. Risdon Bennett, in the " Lancet" for Dec. G, 1851.
 
 ITS TREATMENT. 215 
 
 No such case c;m be treated safely without its administration. 
 Recoveiy may take phice, in certain instances, without it, as 
 indeed, Avithout any other remedy, but that is an argument 
 which applies to almost every disease, and to every kind of 
 treatment, and there is no other remedy of whose curative 
 influence experience and observation have supplied such abund- 
 ant and unequivocal proofs, as of mercury in active serous 
 inflammation. Its efficacy, hoAvever, varies very remarkably, 
 according to the class of cases in which it is employed, as also 
 to the mode in Avhich it is administered, and it is not surprising, 
 therefore, that persons who have exhibited it largely, in all 
 cases of pericarditis, should have met with some in which it 
 has been not inoperative only, but actually prejudicial to the 
 safety of the patient. In most of such cases, the blame should 
 not be charged upon the remedy, but upon those who have 
 injudiciously administered it, for, given in due season and with 
 proper regard to the exigencies of the case, no remedy is more 
 powerful, and few are so trustworthy. 
 
 Opium is, of all remedies, that which comes most powerfully 
 in aid of blood-letting and mercury. Roused and excited as 
 the vascular and nervous systems are by the violence of the 
 morbid action, and the pain which attends it, all remedies prove 
 comparatively useless if unaccompanied by the sedative influence 
 of this narcotic. The constant pain, with the absence of sleep, 
 and the constitutional irritation consequent thereupon, do more, 
 I believe, to exhaust a patient's strength, and counteract the 
 actions essential to his recovery, than blood-letting and mercury 
 can do to promote them. In every case, therefore, of I'hcumatic 
 carditis, opium, in full doses, is indispensable. It should be 
 given not only in doses adequate to restrain the purgative 
 action of the calomel, but in quantity sufiicient to assuage the 
 pain and allay the irritability. From tAvo-thirds of a grain to 
 a grain, or even more, should be prescribed, in the form of a 
 pill, in combination with calomel, every three or four hours ; 
 and in the intervals, if there be much pain, it is expedient to 
 administer eight or ten minims of the tincture, or of Battley's
 
 216 RHEUMATIC INFLAMMATION OF THE HEART, 
 
 sedative solution.^ To the weak and irritable, to whom mercury 
 is of little service, it proves peculiarly valuable. It not only 
 subdues pain, but it allays irritability and procures sleep, and 
 I am satisfied that many of my patients would have fallen 
 victims to the disease, had not their strength been husbanded 
 by its sedative influence. 
 
 It is probable, however, that opium exercises some more 
 directh' curative influence. In these cases of pericarditis, the 
 two inflamed surfaces are in constant motion and rub against 
 one another; their innervation is exaggerated, their irritability 
 exalted. Now, although opium cannot, of itself, prevent the 
 continuance of this friction, it can blunt the sensibility of the 
 inflamed membrane, and make it less obnoxious to the effect of 
 irritation. Just, as before cardiac inflammation has been set 
 up, opium may exercise a sedative influence on the heart, and 
 thus may render it less prone to be aff"ected by the irritation of 
 the rheumatic poison, so, also, I believe, after the commence- 
 ment of mischief, opium may subdue and tranquilize, and thus 
 prevent that excess of irritation whereby the course of inflam- 
 mation is prolonged, and its products made to assume an 
 unhealthy character. In several instances of pericarditis in 
 which, in spite of venesection and mercury, inflammation has 
 continued unabated, while the constitutional irritability has 
 been excessive, and the heart's action rapid and violent, I have 
 seen the mercury omitted and opium administered alone, with 
 the happiest and most speedy results. The pain has ceased, the 
 patient has obtained sleep, his irritability has subsided, the 
 pulse has fallen in frequency, and has increased in steadiness, 
 and the stethoscope, no less than the general symptoms of the 
 disease, has testified to the reality of the improvement. The 
 same train of symptoms was also observed in two cases in which, 
 from the w^eak and cachectic condition of the patients, I was 
 fearful of inducing mercurial action, and therefore trusted 
 exclusively to full doses of opium with alkalies, diuretics, and 
 repeated blistering. The sedative apparently contributed as 
 
 • I find that in these cases, Opium itself is usually preferable to the Salts of 
 Morphia.
 
 ITS TREATMENT. 217 
 
 much to the patients' recovery, as it manifestly did to their 
 comfort. 
 
 Another most important remedy in rheumatic pericarditis is 
 a large blister applied to the chest. In the early stage of the 
 attack, especially in the young and vigorous, I am more inclined 
 to confide in leeches ; but when once effusion has taken place, 
 blistering is of all local remedies the most serviceable. Indeed, 
 its efficacy appears to vary, in some measure, according to the 
 amount of li<|uid effusion, its virtue being most unequivocally 
 displayed when the amount of fluid is greatest. In such cases 
 an immediate diminution in the prgecordial dullness, together 
 with greater clearness in the heart's sounds, is often observed 
 as the result of a large and efficient blister. 
 
 While applying leeches and blisters, and in some instances 
 pushing mercury to salivation, the other general indications 
 must not be lost sight of. Though pericarditis or endocarditis 
 be present, they are still rheumatic, due to the same cause, and 
 requiring the same general treatment for their relief, as does 
 the articular inflammation. Alkalies, diuretics, and colchicum 
 • are still necessary to counteract and get rid of the materies 
 morbi to which all the mischief owes its origin, and without the 
 removal of which it is difficult to conceive that a cure can be 
 effected. Not only are they conducive to the elimination of 
 the rheumatic virus, they also afford most powerful aid to 
 blisters and mercury, in removing the fluid products of inflam- 
 mation. They first assist in counteracting and getting rid of 
 the cause of the disease, and then in repairing the mischief it 
 has occasioned. In endocarditis more especially, alkalies and 
 the neutral salts, more particularly the salts of ammonia,^ prove 
 eminently useful ; for, by helping to maintain the solubility of 
 the fibrin, and so preventing its deposition on the valves, they 
 guard against a lesion which, by the consecutive changes to 
 which it gives rise, leads surely and rapidly to an untimely 
 death. 
 
 In all cases, without exception, rest and abstinence are of 
 the utmost importance. No treatment can be satisfactory in 
 
 1 See Dr. Richardson's " Astley Cooper Prize Essay" for 1856. 
 15
 
 218 RHEUMATIC INFLAMMATION OF THE HEART, 
 
 its issue, unless perfect rest be enjoined, and every cause of 
 excitement carefully guarded against. This has been repeat- 
 edly forced upon my attention in the strongest possible manner. 
 In several instances in Avliich patients liave worked themselves 
 into a state of excitement, in conse(juence of the dread inspired 
 by the thoughts of being leeched, or cupped, or bled, every 
 symptom has been aggravated, in spite of the remedies employed. 
 Indeed, so strikingly was this the case in one instance, that I 
 was obliged to omit all local treatment, and to trust entirely to 
 mercurials and diuretics, with opium in full and repeated doses. 
 
 One other point still remains for consideration — What 
 symptoms are sufficient to warrant such a presumption of the 
 existence of cardiac inflammation as to justify the commence- 
 ment of active treatment? 
 
 This question hardly admits of a definite answer, inasmuch 
 as the symptoms Avhicli mark the accession of carditis are of a 
 complex nature, and, moreover, are uncertain and variable in 
 their existence. In most instances some exocardial friction- 
 sound is heard, or an endocardial murmur accompanying the 
 heart's sounds ; and, together with this, there is anxiety of coun-* 
 tenance, and prsecordial pain and anguish, with dyspnoea, pal- 
 pitation, and irregularity in the heart's action. In such cases 
 there can be little doubt as to the existence of inflammation, 
 and no hesitation, therefore, as to the course to be pursued. 
 The same holds good whenever the physical signs of inflamma- 
 tion are present, even though some of the general signs be 
 wanting. In other instances, however, our attention may be 
 called to the sudden accession of precordial pain occurring 
 coincidently with turbulence, or fluttering, or irregularity of 
 the heart's action; and yet, on examining the heart most 
 carefully, we may fail in detecting the slightest physical indi- 
 cation of existing mischief. What is to be done in such a 
 dilemma? Are we to trust implicitly in the general symp- 
 toms, which are on all hands admitted to be uncertain and 
 fallacious, or are we to delay taking active measures until the 
 presence of inflammation has been rendered indubitable by the 
 presence of the auscultatory signs ? The cautious practitioner 
 
 )
 
 ITS TREATMENT. 219 
 
 will not allow himself to be unduly biased in one direction or 
 the other. The general symptoms must not be relied upon 
 too implicitly, neither must the absence of inflammation be 
 inferred, simply because as yet there is no murmur nor rough- 
 ness with the sounds of the heart. Occasionally a murmur 
 does not arise until inflammation has made some progress, and 
 we are bound, therefore, to commence our treatment before 
 this symptom is developed. Indeed, the frequent occurrence 
 of cardiac inflammation gives such a significance to precor- 
 dial pain, dyspnoea, and palpitation, occurring in the course 
 of acute rheumatism, that even if, on listening most carefully 
 to the heart, we are unable to detect the least change in its 
 rhythm, the least prolongation or roughness of its sounds, 
 or the slightest evidence of pericardial friction, we are still 
 bound to take such precautions as the circumstances of the 
 case may seem to call for. Though we may not feel justified, 
 without some direct evidence of inflammation, in having re- 
 course to active depletion, we shall yet do well to put a few 
 leeches on the chest, and commence the cautious administra- 
 tion of mercury, while watching most jealously for anj;- indi- 
 cation which can fix the seat and nature of the disease, and 
 warrant our taking more active measures. 
 
 When the pericardium is affected, there is sometimes, from 
 the first, a distinct sound of friction, and then, however slight 
 the sound may be, the evidence of mischief is unequivocal, 
 even though there be total absence of pain and other gene- 
 ral symptoms of cardiac inflammation. But it frequently hap- 
 pens that the sound occasioned by exocardial fiiction is at 
 first indistinct, heard only over a small circumscribed space 
 in the prgecordial region, and audible at one moment, inaudi- 
 ble at another. Thus, sometimes for a day or tAvo together, 
 this abnormal sound will be alternately audible or inaudible, 
 until at length it either becomes permanent or ceases altogether. 
 In cases such as this, it would not be right to defer all treat- 
 ment until after the full development of a friction-sound, 
 neither would it be expedient to adopt the active measures 
 required for the arrest of wide-spreading inflammation. These
 
 220 RHEUMATIC INFLAMMATION OF THE HEART, 
 
 indistinct and indefinite yet abnormal sounds, so frequently 
 subside without any treatment, that their presence alone docs 
 not justify our taking any vigorous steps for their removal; at 
 the same time they are so suggestive of evil, and so commonly 
 prove the precursors of extensive mischief, that some precau- 
 tionary treatment should be adopted, and their course nar- 
 rowly watched, in order that the remedies may be pushed 
 more vigorously should their increase betoken active inflam- 
 mation. 
 
 So, again, Avith regard to endocardial disease. When a 
 murmur, known not to have existed before, arises in the 
 course of acute rheumatism, and when, more especially, its 
 commencement is marked by praecordial pain, by increase in 
 the febrile disturbance, and by fluttering or irregularity in 
 the heart's action, then it is to be referred to commencing 
 endocardial mischief, and no time should be lost in employing 
 the full force of our remedial agents. 
 
 Sometimes, however, no distinct murmur exists, but we may 
 distinguish a slight roughness or harshness, or undue prolon- 
 gation of the systolic sound. Even this, if accompanied by 
 prsecordial pain, dyspnoea, and palpitation, is sufficient to 
 excite alarm, and to justify the adoption of measures for its 
 subjugation, inasmuch as such a symptom aff'ords sure evi- 
 dence of mischief, and is the usual forerunner of active in- 
 flammation. The harsh, or rough, or prolonged sound of 
 to-day, is the precursor of the systolic murmur of to-morrow. 
 
 At other times old-standing valvular disease, with its conse- 
 quent old-standing valvular murmur, makes it difficult, if not 
 impossible, to determine by the ear alone, whether any fresh 
 inflammation has been set up. In such a case the activity of 
 the treatment must be regulated, in great measure, by the 
 severity of the general symptoms. 
 
 Not unfrequently a systolic murmur arises which, from its 
 position and the direction in which it is heard, is manifestly 
 connected with imperfect closure of the mitral orifice, yet is 
 unaccompanied by prsecordial pain, dyspnoea, or palpitation, 
 or by any formidable cardiac symptoms. In many such
 
 ITS TREATMENT. 221 
 
 instances the irregular character and short persistence of such 
 a murmur, its frequent recurrence, and its ultimate subsidence 
 without any treatment specially directed to its subjugation, 
 has led me to believe it referable to temporary imperfection of 
 the valvular apparatus consequent on the irregular contrac- 
 tion of the structures connected with the valves. Therefore, 
 although from the first commencement of such a murmur, it is 
 always expedient to have recourse to precautionary treatment, 
 such as the administration of calomel and opium, it would 
 hardly be right to bring the' full force of antiphlogistic reme- 
 dies to bear, unless the murmur persists or increases in 
 intensity, or is accompanied by pain, irregularity of the 
 heart's action, or by some other indication of organic cardiac 
 mischief. 
 
 Sometimes, again, as I can testify from repeated observa- 
 tion, an endocardial murmur arises, in no way connected with 
 inflammatory action, but referable altogether to functional 
 causes ; and although the superficial position of such a mui'- 
 mur, and the direction in which it is heard, viz., along the 
 track of the pulmonary artery, when coupled with the pale 
 exsanguine appearance, and exhausted condition of the patient, 
 serve, in most cases, to distinguish it from a murmur attribut- 
 able to organic mischief, still, if considerable caution be not 
 observed, it may be mistaken for a murmur the result of in- 
 flammation, and treatment may be adopted ill suited to the 
 circumstances of the case. 
 
 The greatest care, then, is requisite in listening to tlie car- 
 diac sounds. The heart should be examined daily, and the 
 least deviation from health noted. The slightest prolongation, 
 or unnatural harshness, or roughness of its sounds, is sufficient 
 to excite alarm, and the least suspicion of inflammation is 
 enough to justify some precautionary treatment. But until 
 the existence of inflammation is placed beyond doubt, it is not 
 necessary, nor indeed would it be prudent, to push our meas- 
 ures so vigorously as otherwise would be deemed essential. 
 The remedies to be employed are the remedies for inflamma-
 
 222 UIIEUMATIC INFLAMMATION OF THE HEART, 
 
 tion, but tliev should be duly apportioned to the exigencies of 
 the case. 
 
 There is yet one point which requires notice in connection 
 •with these endocardial murmurs. It is, that during the con- 
 valescence of a patient, even after he has risen from his bed. 
 and has begun to walk about the room, a valvular murmur 
 will sometimes make its appearance, and, unless immediately 
 attended to, will remain permanent. In these instances the 
 murmur itself affords the first intelligence of mischief; for, 
 although there generally exists some irritability about the 
 heart, there is no pain, and no unusual palpitation. Even 
 during convalescence, then, the heart must be constantly and 
 carefully examined, and on the first indication of change in the 
 character of its sounds, most active treatment must be had 
 recourse to ; treatment active not in its essential character so 
 much as in the rapidity with which it is pushed. In these 
 cases there probably exists some chronic irritation of the valves, 
 and when the rapidity of the circulation is subsiding, fibrin is 
 deposited just as it often is in the rheumatic diathesis, inde- 
 pendently of any paroxysm of acute rheumatism, and just as it 
 was seen to be with the gradual cessation of the circulation in 
 Dr. Hope's experiments on the ass. The remedies most poAv- 
 erful in preventing its further deposition, and in effecting its 
 removal, are alkalies and the neutral salts, with opium, in full 
 doses, and niercur}^, cautiously administered. 
 
 In every instance in which, after all active symptoms have 
 subsided, there still remains much irritability of the heart, it is 
 expedient, while attending to the general health, to administer 
 occasional doses of opium and digitalis, and to apply an opium 
 or a belladonna plaster to the chest. By such precautionary 
 measures, and by enforcing that rest which is necessary to 
 enable the excited heart to recover itself and reassume its 
 natural mode of action, we may guard, in great measure, 
 against those lesions which, arising after all inflammatory 
 action has been subdued, are due to the existence of chronic 
 irritation rather than of true inflammation. 
 
 The following cases will serve as illustrations of the treat-
 
 CASES ILLUSTRATING ITS TREATMENT. 223 
 
 ment recommended, smU of thfe share ■which each remedy takes 
 in effecting the cure. 
 
 Case I.^ — Fanny Nicholls^ ^^i pale-faced girl, j^et. 19, -was 
 admitted into ^liie Queen's Ward of St. George's Hospital, on 
 the 31st of December, 1850. She had been attacked, on 
 Christmas Day, with redness and swelling of the joints, and all 
 the usual symptoms of rheumatic fever. On admission into the 
 hospital these symptoms continued Avith increased severity. 
 The sounds of the heart were clear ; but as she complained of 
 pain in the prsecordial region, it was judged expedient to put 
 her under the influence of mercury, and the following pill was 
 therefore ordered : 
 
 I^. Hydrarg}-ri Cliloridi, gr. iij ; Opii, gr. j. M. ft. Pilula G''^ boris 
 sumenda. 
 
 January Xat. — The next day the sounds of the heart still 
 remained clear, and there was no increased dullness on percus- 
 sion in the precordial region, but she complained, as before, 
 of pain in the chest, and the pulse was 120 and stronger ; so 
 it was judged advisable to 7-epeat the pill every four hours, and 
 to give her a saline effervescing draught with gr. xv of Nitrate 
 of Potash. 
 
 So she went on until the 4th instant. Day by day her 
 heart was carefully examined, but on no occasion could any 
 evidence of mischief be obtained. My friend and colleague. 
 Dr. Bence Jones, under whose treatment she had been placed, 
 was now called away from town, and she was transferred to my 
 care. Early in the morning her chest had been examined, and 
 the heart's sounds reported free from murmur ; but when I 
 first saw her in the afternoon she was complaining of increased 
 pain in the cardiac region, and an incipient exocardial friction- 
 sound was audible at the base of the heart, and a slight systolic 
 murmur at the apex. There was, as yet, no extension of the 
 
 1 This is the only case in which I have ever known extensive pericarditis 
 subdued and the friction-sound got rid of, within six days from the date of its 
 commencement. Such a speedy termination of the disease cannot usually he 
 brought about even by the most judicious treatment.
 
 224 RHEUMATIC INFLAMMATION OF THE HEART, 
 
 natural praecordial dullness. Her joints were still red and 
 swollen ; the gums were unaffected by the mercury. Pulse 
 120, full, and somewhat irregular, skin perspiring freely, 
 tongue furred, and bowels confined. Urine reported scanty 
 and turbid, but none had been saved for examination. The 
 inflamed joints were wrapped up in flannels soaked in an alka- 
 line and opiate fomentation, and as she did not appear to be 
 ver}' susceptible of the influence of mercury, I ordered a drachm 
 of the Mercurial ointment to be rubbed in night and morning, 
 on the chest, and the Calomel and Opium pill to be repeated 
 every four hours, as before. The following draught was also 
 ordered to be taken between each dose of the pills : 
 
 I^. Haust. Salinus efFervescens c. Potassa^ Xitratis, gr. xv ; 
 
 Sodce Potassio-Tart., 3ij ; 
 Tincturae Opii, ^x. 
 
 On the 5th she remained much the same. The sound of 
 friction was not so loud as on the preceding day, but it had 
 become universally diffused over the heart, and there was 
 increasing dullness in the pn^cordial region, showing the exist- 
 ence of effusion in the pericardium. As the gums were not 
 affected by the mercury, the medicines were continued as 
 before. 
 
 On the 6th she was better in some respects. She had slept 
 a little during the night ; her pulse had fallen to 104 ; the 
 urine, though still extremely acid and turbid, was more 
 abundant, and her joints were far less painful. Nevertheless, 
 the exocardial friction-sound Avas very loud, and the pme- 
 cordial dullness more extended ; so a large blister was ordered 
 to be placed over the heart ; the Calomel and the Mercurial 
 inunction were continued as before, and ten minims of the 
 Vinum Colchici were added to the draught. This I thought 
 likely to prove serviceable from its diuretic no less than from 
 its antirheumatic properties. 
 
 On the Tth there was very little alteration in her symptoms, 
 except that the ui'ine had become abundant and almost clear, 
 sp. gr. 1026, and the bowels showed a tendency to relaxation. 
 The blister had risen well and was discharging freely. The
 
 CASES ILLUSTRATING ITS TREATMENT. 225 
 
 gums were still unaffected by the mercury, but as the bowels 
 were becoming irritable, the inunction was discontinued, and 
 fifteen minims of the Tr. Opii were given with each dose of the 
 medicine. The pills were repeated as before. 
 
 On the 8tli there was manifest improvement. She had slept 
 about two hours during the night ; her pulse had fallen to 80, and 
 the urine continued clear, abundant, sp. gr. 1025. The blister 
 was still discharging freely; there was less extended dullness 
 in the region of the heart, and the friction-sound, though still 
 loud at the base of the heart, was no longer audible at the 
 apex. There was still a slight tendency to diarrhoea, but as 
 the gums were unaifected, the pills and the draught were con- 
 tinued as before. 
 
 On the 9th the favorable progress of the disease was more 
 marked. The dullness on percussion in the prjecordial region 
 was now scarcely more extended than natural, and the friction- 
 sound was confined to the base of the heart. The systolic 
 bellows-sound had quite disappeared. The relaxation of the 
 bowels still continued, though not to a distressing extent; so, 
 as the mouth was as yet unaffected by the mercury, the pills 
 and draught were repeated. 
 
 On the 10th the inflammation of the heart was subdued. 
 There was no longer any extension of the prsecordial dullness, 
 and no longer any friction-sound or endocardial murmur. The 
 pulse Avas 84, soft; the urine clear and abundant, and the 
 tongue much cleaner. There was neither redness nor tender- 
 ness of the gums, but the relaxation of the bowels had in- 
 creased, and the diarrhoea was evidently due to mercurial action, 
 so I ordered her to omit the pills. The draught was continued 
 as before, and a pill was given at bedtime, containing three 
 grains of calomel and two of opium. 
 
 On the 11th, the diarrhoea still continuing, the dose of 
 potassio-tartrate of soda was reduced to a drachm ; and on the 
 13th, as her aspect was greatly improved, the pulse quiet, the 
 tongue moist and almost clean, the salines were omitted, and 
 a quinine draught was administered twice a day, Avhile her 
 bowels were quieted by Dover's powder. From this time her
 
 226 RHEUMATIC INFLAMMATION OF THE HEART, 
 
 convalescence proceeded steadily; and Avhen she left the house, 
 on the 5th of February, her heart was acting regularly and its 
 sounds were clear and free from murmur. 
 
 Case II. — Sarah Cowley, set. 23, was admitted into the 
 Rosebery "Ward of St. George's Hospital, on the 8th of August, 
 1851, laboring under acute rheumatism of nine days' duration. 
 She had undergone an acute attack of tlie disease four years 
 ago, but from that time had remained free from pain until the 
 commencement of the present illness. On admission, her left 
 hand, right knee, and ankle were exquisitely painful, and were 
 red, swollen, and inflamed; skin hot, but not perspiring; tongue 
 yellowish, furred, and somewhat dr}^; bowels open ; urine scanty 
 and strong smelling, high colored, and loaded with the lithates, 
 sp. gr. 1020 ; saliva acid. The menstrual periods were reported 
 regular. Her countenance was anxious; the breathing short 
 and catching; and she complained of much pain in the region 
 of the heart. Not the slightest evidence of exocardial friction 
 could be detected ; but a loud, harsh murmur, heard loudest at 
 the apex of the heart, accompanied and almost overpowered 
 the first sound of the heart. The pulse was 100, somewhat 
 hard and irregular. 
 
 The inflamed joints were fomented as usual, and the follow- 
 ing remedies were prescribed: 
 
 Ilirudines x, region! cordis. 
 ^. Hydr Chloridi, gr. iij ; Opii,gr. j. M. ft. Pilula, 4"» quAque borA sumenda. 
 
 Haustiis Potassic Xitratis, 5JSS ; Sodie Potiissio-Tarl., 5'j j ^'i°i Colchici, 
 Ti\xv; Tiact. Opii, ^n^iij- 
 
 M. ft. Haustus 4'"' boris alternis sumendus. 
 Fever diet. 
 
 9th. — She dozed at intervals during the night, and perspired 
 freely. The next day the joints were much easier, and the 
 urine more abundant; sp. gr. 1028. The heart's sounds, how- 
 ever, were much the same, and there was still some pain at the 
 heart. The pulse was 100, the tongue coated, and somewhat 
 dry, and the bowels rather relaxed.
 
 CASES ILLUSTRATING ITS TREATMENT. 227 
 
 Rep. Hirudines vj. regioni cordis. 
 
 Repetatur Pilula 4''^ horis. 
 Rep. Haustus 4'''* horis alternis, sod c. Tincturffi Opii, TiXxv. 
 
 10th. — Dozed at intervals throughout the night, and is much 
 better this morning. Has no longer any redness or swelling 
 of the joints, or any pain in the chest except after exertion, as 
 from turning in bed. Systolic murmur still present, but less 
 loud and harsh. Perspires freely. Pupils rather contracted. 
 Tongue coated. Bowels much relaxed. No urine had been 
 saved for examination, but it was reported free and no longer 
 turbid. Gums not affected. 
 
 As the force of the disease was evidently checked, and the 
 opium, though given in sufficient quantity to cause contraction 
 of the pupils, had failed to restrain the purgative action of the 
 mercury, and to allay the irritation to which it gave rise, the 
 pills were repeated only twice a day. The draught was con- 
 tinued as before. 
 
 lltJi. — She passed a better night, and the next day reported 
 herself almost free from pain. She was perspiring freely. 
 Gums becoming red, swollen, and tender. Bowels much re- 
 laxed. No urine saved for examination, but reported abundant 
 and clear. Pulse 116, weak and irritable. A systolic murmur 
 still perceptible, though less loud and harsh than it was yes- 
 terday. 
 
 As the rheumatic symptoms were now almost subdued, the 
 pills and draught were omitted, and a grain of opium was given 
 every six hours. The next day — 
 
 12^A. — As the skin was becoming sodden, a quinine draught, 
 with a few minims of the dilute sulphuric acid, was ordered to 
 be taken twice a day; and, as the bowels had not been relieved, 
 3SS of the sulphate of magnesia was added. x\t the same time, 
 by way of precaution against a relapse, a pill was given at 
 night, containing a grain of opium and two grains of the acetous 
 extract of colchicum. 
 
 From this time she improved daily. By the 14th she had 
 no longer any pain, the heart's action was much quieter, and 
 the murmur softer. On the 16th she was so much more tranquil,
 
 228 RHEUMATIC INFLAMMATION OF THE HEART, 
 
 and all her symptoms showed such decided improvement, that 
 I deemed it unnecessary to continue the pill, and therefore 
 ordered her to take the quinine draught only. By the 18th 
 the murmur had become so faint, that at times the ear almost 
 failed to appreciate it, and in other respects she was conva- 
 lescent. However, as she was very pale, five grains of the 
 Pilula Ferri co. were given three times a day, in addition to 
 the quinine; and this she continued taking up to the 3d of 
 September, when she left the house, her health being com- 
 pletely re-established. A slight systolic mitral murmur, how- 
 ever, still existed. 
 
 Case III. — Harriet Pope, a pasty-faced girl, set. 17, was 
 admitted into the Princess AVard of St. George's Hospital on 
 the 3d of September, 1851, suffering from acute rheumatism. 
 The present was her first attack. It began five days before 
 admission, with pain, heat, redness, and swelling of the feet, 
 ankles, and the left knee ; but when I first saw her in the hos- 
 pital, the feet and ankles alone were affected. She was 
 perspiring freely ; tongue coated and white ; urine acid, high 
 colored, and rather scanty, sp. gr. 1014; bowels reported open; 
 pulse 130, weak but regular. She had no pain in the region of 
 the heart, nor was there any extension of the prjecordial dull- 
 ness ; but there was a slight roughness with the first sound at 
 the apex of the heart, and an indistinct irregular double mur- 
 mur, which gave the idea of a commencing exocardial friction- 
 sound at the base of the heart. 
 
 I ordered eight leeches to be applied to the region of the 
 heart, the inflamed joints to be fomented as usual, and pre- 
 scribed the following : 
 
 I^. Hydrarg3Ti Chloridi, gr. iij ; Opii, gr. j, ter in die. 
 
 Hiiustus SenniTJ c. SodiU Potassio-Tart., 5iv, eras mane. 
 
 Haust. Potassix) Citratis, §is9 ; 
 
 Sodae Potassio-Tartratis, 5ij ; 
 
 Vini Colchici, "nj^xv; 
 
 Liq. Opii Sed (Battlei), lt|.viij ; G"' quaque bora. 
 
 Sept. 4th. — The next day she was decidedly worse. The
 
 CASES ILLUSTRATING ITS TREATMENT. 229 
 
 pains in the joints were easier, but she had not slept ; her 
 countenance was anxious, the pulse 140, extremely weak, 
 irregular, and occasionally intermittent, and she exhibited 
 extreme disinclination to change her posture. There was still 
 no pain at the heart, but extended dullness on percussion in the 
 prgecordial region, with great obscurity and distance of the 
 heart's sounds, showed that effusion into the pericardium had 
 taken place with unusual rapidity. A distinct exocardial fric- 
 tion-sound could be heard now and then at the base of the heart. 
 The bowels had acted twice- after the Senna ; the tongue was 
 furred, but moist. No urine had been saved for examination ; 
 it was reported scanty. 
 
 Hirudines xij, region! cordis et postea emplastrum Cantbaridis. 
 Repetatur pilula 6''^ horis. 
 Repetatur haustus G^'^ horis alternis. 
 
 5th — The next day there were signs of amendment. She had 
 slept fairly ; the pains in the joints were slight, and the swell- 
 ing had entirely disappeared ; the pulse had fallen to 120, and 
 was much more regular ; the praecordial dullness was less 
 extended ; the sounds of the heart were less distant, showing 
 absorption of the fluid in the pericardium ; and a loud to-and- 
 fro sound of friction was now audible over the entire surface of 
 the heart. The countenance, however, was still distressed and 
 anxious. She was perspiring freely. The urine was reported 
 to have been passed in much larger quantity : a small quantity 
 which had been saved had a sp. gr. of 1028. 
 
 Repetantur Medicanienta. 
 
 6tJi. — She passed a restless night, and the next day exhib- 
 ited more anxiety of countenance, and in many respects a 
 material aggravation of her symptoms. She now, for the first 
 time, complained of pain at the heart, and of dyspnoea, with 
 occasional cough ; there was sonorous rhonchus all over the 
 chest ; the heart's sounds were again more obscured ; the prge- 
 cordial dullness had again extended itself; and the pulse Avas 
 120, and irregular. The skin was hot and perspiring ; but the 
 discharge from the blister had almost ceased. 
 
 Repetatur emplastrum Cantharidis regioni cordis. 
 Perstet in usu Medicamentorura.
 
 230 RHEUMATIC INFLAMMATION OF THE HEART, 
 
 ItJi. — The following day the pain at the heart continued, and 
 the increase of eifusion was manifested by the total cessation of 
 the friction-sound, by the distance and feebleness of the heart's 
 sounds, which had become almost inaudible, and by the dullness 
 on percussion which now extended over to the right side of the 
 sternum. Her countenance was very anxious ; the pulse, how- 
 ever, had fallen to 100, and, though feeble, was tolerably steady ; 
 the bowels had acted once comfortably ; and she had no longer 
 any pains in the joints. No urine had been saved, but it was 
 reported tolerably abundant. The gums were not affected, so 
 mercurial ointment was applied to the blistered surface, the pill 
 was repeated every six hours, as before, and a diuretic draught, 
 containing Potassee Nitratis, gr. x, Tr. ScilljB, "ixv, Tr. Can- 
 tharidis tt^xx, was substituted for the saline medicine she had 
 hitherto taken. 
 
 ^th. — The next day mercurial action was more decided, and 
 she was manifestly better. Her countenance was less anxious ; 
 the extent of dullness on percussion had diminished, the friction- 
 sound was again audible, the sounds of the heart were loud, and 
 the pulse had fallen to 96. The bowels were somewhat relaxed. 
 
 Perstet in nsu hausti'is diuretici. 
 
 Repetatur pilula bis in die tantura. 
 
 Opii, gr. j, liora soinni. 
 
 S}th. — Cojitinucd improvement. Gums fully affected. Sounds 
 of the heart clearer, and friction-sound very loud. Less 
 extension of the natural priecordial dullness. Pulse 90, regu- 
 lar. Bowels much relaxed, with green mercurial motions. 
 
 Perstet in usu haustus diuretici. 
 
 Omittantur pilulae. 
 
 Opii, gr. j, bis in die. 
 
 From this time her improvement was steady and progressive. 
 On the 12th I thought it expedient to apply another blister on 
 the chest, with the view of accelerating the absorption of the 
 matters effused into the pericardium, but with this exception, 
 no alteration was made in the treatment until the 4th of Octo- 
 ber, when, as the endocardial murmur was no longer audible, 
 and the pulse was weak, a drachm of the Tinct. Cinchonae was
 
 CASES ILLUSTRATING ITS TREATMENT. 231 
 
 added to the draught. When she was able to move easily in bed 
 and shift her position, so as to submit to a careful stethoscopic 
 examination, some little dullness was discovered at the base of 
 the right lung posteriorly, and legophony was also audible 
 there ; but as there was no pain on inspiration, no distress of 
 breathing, and no quickness or sharpness of the pulse indica- 
 ting existing inflammation, no treatment was specially directed 
 to it, but the diuretic mixture was continued as before. By the 
 9th of October the segophony had disappeared, healthy respi- 
 ration was re-established throughout the chest, and the heart's 
 sounds were clear and free from murmur, so the diuretics were 
 omitted, and a quinine draught ordered. This she continued 
 taking until the 21st instant, when she left the hospital ; the 
 heart's action being regular, its sounds perfectly free from 
 murmur, and the respiration natural. 
 
 Case IV. — On the 19th of January, 1847, I was asked to 
 see Master F. — , set. 8, who had been seized that morning 
 by acute pain in the right elbow and the left shoulder, and on 
 the left side of the chest. The pain attacked him suddenly, 
 without rigors or any previous warning. He was unable to 
 bend his right arm, or to raise the left arm to his head, and 
 could not bear pressure on either of the affected joints or on 
 the peetoralis major. Skin hot and perspiring. Tongue fur- 
 red. Bowels costive. Urine loaded. Pulse 130, rather sharp. 
 Heart's sounds free from murmur. Perspiration free. Five 
 grains of Calomel, followed by a black draught, aided by 
 some saline medicine, with ten grains of Niter, fifteen minims 
 of Colchicum Wine, and fifteen minims of the Vinum Antimo- 
 niale, got rid of the pains within twenty-four hours, and I saw 
 nothing more of him until tlie 24th, when I was again asked 
 to see him. He was then complaining of faintness, with pal- 
 pitation and a stabbing pain under the left breast. This pain 
 was increased by pressure under the ribs on the left side, as 
 also by the effort of coughing. There was no pleuritic fric-
 
 232 RHEUMATIC INFLAMMATION OF THE HEART, 
 
 tion nor fegopliony, nor were there any of tlie fine crepita- 
 tions of pneumonia, but a loud to-and-fro sound of friction 
 was audible over the whole of the cardiac region. There were 
 now no pains in the limbs. Skin hot and perspiring, the per- 
 spiration having the pecnliarly sour odor of rheumatism. 
 Tongue very furred. Bowels open. Urine turbid and scanty. 
 Pulse 120, sharp, irregular, and occasionally intermittent. 
 
 Eight leeches were placed at once over the heart, and were 
 followed by a large blister ; and the following medicine was 
 prescribed : 
 
 I^. Hydrargyri Chloridi, gr. iij ; 
 
 Opii, gr. ss. M. ft. Pilula 4"^ horis sumenda. 
 
 Haustus Salini ex Ammonia, ^jss ; 
 
 Potassae Nitratis, gr. x ; 
 
 Potassaj Tartratis, 5ss ; 
 
 Villi Colchici, ^viij. M ft. Haustus 4"^ horis altemis sumendus. 
 
 iQth. — Dozed during the night, and is much as he was yes- 
 terday. Tlie blister rose well, but the friction-sound has 
 ceased, the heart's sounds have become feeble, distant, and 
 muffled, and there is extended dullness on percussion in the 
 cardiac region. Evinces a tendency to faint. 
 
 Repetantur piluUB et haustus 4"'* horis. 
 Unguentum Hydrargyri parti vesicatte. 
 
 26^7i. — No return of friction-sound. Further extension of 
 prgecordial dullness. Is very irritable. In other respects 
 much as yesterday. No mercurial action. 
 
 Repetantur medicaraenta 4'* quaque hora. 
 Rep. emplast. Cantharidis region! cordis. 
 I^. Pulv. Ipecacuanh;e co., gr. v, hora somni. 
 
 Ilth. — Slept fairly. The blister rose well, and to-day there 
 Is considerable improvement. Less extended dullness in the 
 precordial region. Friction-sound again audible over the 
 whole extent of the heart, and the sounds of the heart much 
 
 louder. 
 
 Rcpetatur piluhi sextis horis. 
 Perstct in usu haustus, sed adde Tr. Scillie, Ti|xl, Tr. Cantharidis, tt^xx. 
 
 During the next four days a gradual improvement was per- 
 ceptible ; the heart's sounds became clearer and louder ; the
 
 CASES ILLUSTRATING ITS TREATMENT. 233 
 
 dullness on percussion decreased ; the urine increased in quan- 
 tity, and the tendency to faintness ceased ; the friction-sound, 
 however, continued, and was heard over the whole heart, and 
 the system gave no token of being affected by the mercury. 
 
 On the 1st of February, contrary to my express injunc- 
 tions, he had been allowed to see and talk to some of his 
 friends, sit up in bed, and otherwise exert himself, and when 
 I visited him in the evening his symptoms were materially 
 aggravated. The pulse, which for the last five days had aver- 
 aged 100, had again risen to 130 ; the heart's sounds were less 
 clear, and the dullness in the mammary region had increased. 
 There was as yet no evidence of mercurial action, so the pills 
 and draughts were repeated every six hours, as before, and 
 another blister was applied to the chest. The bowels being 
 somewhat confined, a senna draught was administered. 
 
 The beneficial influence of the blister was soon displayed, in 
 the increased steadiness of the heart's action, and the clear- 
 ness of its sounds ; and, by the 5th, the symptoms were much 
 the same as before his relapse. The friction-sound was very 
 loud, and the prsecordial dullness had greatly diminished. 
 About this time I had the benefit of a consultation with Dr. 
 Watson, and, as there was still no mercurial action, it was 
 decided that the pills and draughts were to be continued as 
 before. He now slept well, and passed large quantities of 
 urine, and day by day his symptoms betokened gradual 
 amendment. The heart's sounds became clearer, and the 
 friction-sound less intense. The gums were slightly swollen, 
 and rather more red than natural, but there W'as no mercurial 
 fetor, no increased flow of saliva, and no evidence of full mer- 
 curial action. 
 
 By the 11th the friction-sound had disappeared, so the pills 
 were omitted. On the folloAving day, as the improvement was 
 fully maintained, a draught was ordered to be taken twice a 
 day, containing half a drachm of Nitric Ether, eight grains of 
 Nitrate of Potash, and an ounce of the infusion of Cascarilla ; 
 and, as the action of the heart was still turbulent, a bella- 
 donna plaster was applied to the chest, and a pill given every 
 16
 
 234 RHEUMATIC INFLAMMATION OF THE HEART. 
 
 night at bedtime, containing half a grain of powdered digi- 
 talis, a quarter of a grain of opium, a grain of powdered 
 squills, and two grains of blue pill. Under this treatment he 
 improved rapidly, and on the 20th it was judged safe to omit 
 the medicines he had been taking, and to give him a quinine 
 mixture, perfect rest being strictly enforced. He continued 
 to take the tonic until the 28th, when, as the heart's action 
 was regular and tranquil, and his appetite good, the medicine 
 was discontinued. 
 
 I have seen him occasionally, during the holidays, ever 
 since this attack, and the heart's sounds remain clear, and its 
 action regular. Its impulse is somewhat stronger than natu- 
 ral, but I cannot perceive that there has been any material 
 increase in this respect during the last seven years. As yet 
 there has not been the slightest recurrence of rheumatic 
 symptoms.
 
 CHAPTER IX. 
 
 ON THE STATISTICS OF HEART DISEASE IN CONNECTION 
 WITH RHEUMATISM. 
 
 The statistics of heart disease in connection with rheumatism 
 form a subject deserving of attentive study, not only on account 
 of their practical importance to the physician who is ca;lled 
 upon to prognosticate as to the favorable or unfavorable issue 
 of his patient's malady, but as tending to elucidate several 
 important matters on which much loose speculation has been 
 hazarded. That inflammation of the heart, or, as it is com- 
 monly designated, "rheumatism of the heart," is a, frequent 
 accompaniment of rheumatic disease, and forms a, fearful addi- 
 tion to articular pain and inflammation, has, alas! been fully 
 verified by thousands who, sooner or later, have fallen victims 
 to its ravages. But the probability of its occurrence in any 
 particular instance, the age and sex of its victims, the form of 
 rheumatism in which, and the stage of the disease at which its 
 invasion is most to be dreaded, the relative frequency of the 
 difi'erent forms which it assumes, and the eff"ect of remedies in 
 warding ofi" its attacks, — these are points on which the number 
 of observations hitherto recorded are insufficient to warrant 
 our speaking with certainty. Dr. Latham, Dr. Taylor, and 
 other inquirers have done much toward clearing up existing 
 doubts on some of these matters, but no one can feel satisfied 
 on a subject of so much importance until their results have 
 been verified by further investigation. 
 
 Much difficulty has occurred to me, in instituting a com- 
 parison between the result of my experience at St. George's 
 Hospital and that which others have put on record, from the 
 fact that a wide diff'erence exists between the grounds which 
 have been chosen as the foundation of the various calculations. 
 Some persons, for instance, in dividing febrile rheumatism into
 
 236 STATISTICS OF HEART DISEASE 
 
 an acute and a subacute class, have included many cases in 
 the former, which others would have placed in the latter; and 
 some have arranged in their subacute class many cases which 
 others would have denominated chronic. Some have been 
 guided in their classification solely by the intensity of the 
 articular inflammation ; some by the severity of the febrile 
 paroxysms; while others, taking the mixed indication afforded 
 by the fever and the articular pain and inflammation, have 
 arranged and classified their cases accordingly. Hence one 
 fertile source of uncertainty and confusion. Judging from my 
 observation of the nomenclature adopted at several of our 
 larger public institutions, I believe that cases are often termed 
 "acute," which I should denominate "subacute;" I have there- 
 fore discriminated, in separate tables, between the undoubtedly 
 acute cases, and those which, as marked by less violent symp- 
 toms, may be regarded as instances of less active disease.^ 
 
 Another productive source of error is the great variation in 
 the mode in wliicli the diff"ercnt classes of cases have been 
 grouped for the purpose of examination. Nothing can be 
 
 ' [Jnder the head of Acute Rheumatism, I have classed all cases io which 
 the febrile paroxysm has been "acute," and accompanied by the profuse acid 
 perspirations, which are eminently characteristic of the acute disease ; while 
 under the head of "subacute," I have arranged all cases in which the fever 
 has assumed a milder form, and the articular symptoms have been less acute, 
 though marked, perhaps, by pain, and redness, and swelling. Cases which 
 have not been attended by a well-marked febrile movement, even though ac- 
 companied by cedematous fullness about the joint, or by slight effusion within 
 the capsule, I have placed under the head of " chronic." In making this 
 division, I have allowed myself to be guided by the amount of the fever, rather 
 than by the severity of the articular inflammation, under the belief that the 
 fever and the arthritis, carditis, pneumonia, pleurisy, and other local symptoms 
 which often accompany the acute form of rheumatism, are the results of one 
 common cause, and that the fever affords a more certain indication of the 
 amount of poison present in the system, than does the arthritis, which experi- 
 ence has shown to be sometimes absent, even when the fever is very severe, 
 and attended by acute inflammation of the heart. Moreover, the conviction 
 has been forced upon me, that the extent and number of the internal compli- 
 cations bear a more constant relation to the amount of febrile movement than 
 to the number and intensity of the articular inflammations, and that the fever 
 is a fair exponent of the probability of secondpry affections in rheumatism, 
 just as Louis has shown it to be in typhoid fever, and many other acute dis- 
 orders.
 
 IN CONNECTION WITH RHEUMATISM. 237 
 
 raore certain than that the frequency of heart disease varies 
 greatly, according to the type and severity of the rheumatic 
 affection; and the proportion of cases in which heart disease 
 is met with, must vary therefore according as the conclusions 
 of different observers have been drawn from acute or subacute 
 cases, or from both classes of cases taken conjointly. In some 
 instances on record, it is stated that the conclusions have been 
 arrived at from the examination of acute and subacute cases 
 taken indiscriminately: in others, it is impossible to ascertain 
 with certainty the precise nature of the cases from which the 
 recorded results have been obtained. The numbers, however, 
 agree so closely in some instances with those obtained from 
 acute and subacute cases taken conjointly, that I cannot help 
 thinking they must have been deduced from a class of cases in 
 which the subacute were included with the more acute examples 
 of the disease. Indeed, I hope to show that the differences 
 existing in the very foundation of all the subsequent calcula- 
 tions account for most of the discrepancies which exist between 
 the reports of various observers. 
 
 The cases from which my inferences are drawn are 379 in 
 number. They embrace all the examples of acute and subacute 
 rheumatism which were admitted into St. George's Hospital 
 under the care of the physicians, during the time I held the 
 office of Medical Registrar, namely, between the 1st of January, 
 1845, and the 1st of May, 1848, and include 246 examples of 
 the disease in its more acute form, and 133 of a milder charac- 
 ter. The heart was healthy in 160 instances; in 32 I have no 
 note of its condition, and probably, therefore, it was healthy; 
 and in 187 it was either temporarily or permanently deranged 
 to a greater or less extent. Three tables, exhibiting an analysis 
 of these cases, are appended to this chapter.^ 
 
 Of the 187 cases of heart disease, 130 were examples of 
 recent mischief,^ as was evidenced, either by the supervention 
 
 1 See pp. 253-50. 
 
 ^ It, must not be understood, tliat in all these cases, the be.art was previously 
 free from disease, neither must it be inferred that the endocardial murmur 
 which existed, was invariably referable to organic mischief. These are points 
 on v,'hich positive information cannot usually be obtained. I only wish to imply^
 
 238 STATISTICS OF HEART DISEASE 
 
 of a murmur, after the patient's admission into the hospital, 
 or by the existence of a murmur wliich, though present at the 
 date of the patient's admission, was found to subside toward 
 the close of the disease, or was coincident with prgecordial pain 
 and anguish, or with temporary irregularity in the heart's 
 rhythm ; in 18 the date of the mischief was doubtful ; and in 
 39 the absence of inflammatory symptoms referable to the 
 heart, together with the manifest enlargement of that organ, 
 and the little alteration which the sounds underwent during 
 the time the patient was under notice, induced a belief that 
 the disease was of old standing. Now, supposing that 9 out 
 of the 18 doubtful cases were examples of recent mischief, and 
 9 of old-standing disease, we get an aggregate number of 139 
 instances of recent, and 48 of old-standing cardiac disease, 
 among 379 cases of acute and subacute rheumatism taken in- 
 discriminately. In other words, we find that some form of 
 heart affection existed in about half the cases (1 in every 2*02) 
 of acute and subacute rheumatism taken conjointly; some recent 
 mischief in more than one-third, (1 in every 2-7,) and some old- 
 standing mischief in one out of about every eight, (1 in every 
 7-9.) 
 
 This is the result when acute and subacute cases are viewed 
 collectively; and it is sufficiently formidable in its character. 
 But it assumes a still more serious aspect when the acute are 
 separated from the subacute cases, and are traced in their con- 
 nection with the cardiac disease. Of the 130 instances of recent 
 cardiac mischief, no less than 114 occurred among the class of 
 acute rheumatism, as did also 10 of the doubtful cases, and 21 
 of the cases of old-standing disease, making in all 145 instances of 
 
 that in 130 instances, the heart was implicated to a greater or less extent 
 during the then existing attack of rheumatism, as was indicated by a tempo- 
 rary or permanent exocardial or endocardial murmur. In seventeen cases the 
 prior existence of heart affection was clearly ascertained, and in several others 
 was strongly suspected, and in some, doubtless, the existence of a valvular 
 murmur was attributable altogether to functional causes. Any attempt, how- 
 ever, to enumerate the cases in which I believe the heart to have been previ- 
 ously affected, or the murmur to have arisen from functional causes, might 
 possibly lead to error, and I have therefore abstained from hazarding an opinion 
 ou either of these points.
 
 IN CONNECTION WITH RHEUMATISM. 
 
 239 
 
 heart disease among 246 examples of acute rheumatism. Now 
 supposing, as before, that half the doubtful cases were instances 
 of recent, and half of old-standing gardiac mischief, we find the 
 heart affected svith recent disease in 119 instances, and with old- 
 standing disease in 26 instances, among 246 patients afflicted 
 with acute rheumatism. In other words, we find some heart 
 affection in about three-fifths (1 in every 1*7) of all the cases ; 
 we get evidence of recent heart disease in almost one-half, (1 
 in every 2*06 ;) and of old-standing disease in about one in 
 every nine and a half, (1 in every 9*4.) 
 
 On the other hand, taking subacute rheumatism alone, a 
 remarkable decrease is observed in the proportion of cases in 
 which the heart is afiected by pericarditis and other recent 
 disease, and an equally striking increase in the proportion of 
 old-standing cardiac affection. Among the 133 patients suffer- 
 ing from subacute rheumatism, there were 42 instances of 
 cardiac disease ; and of these, 16 were examples of recent 
 affection of the heart; in 8 the date of the mischief was uncer- 
 tain ; and in 18 it was obviously of old standing. Dividing 
 the aoubtful cases as before, we obtain 20 as the aggregate 
 number of instances in which the heart was recently affected, 
 and 22 as the number in which it was previously diseased. In 
 short, some form of heart disease appears to accompany about 
 one-third (1 in every 3-1) of all cases of subacute rheumatism ; 
 some recent heart affection, one in about every six and a half, 
 (1 in every 6*6 ;) and some old-standing disease, one in every 
 six, (1 in every 6'04.) 
 
 The difference of these results will be manifest from an in- 
 spection of the following table, in which they are collocated 
 and contrasted : 
 
 No. of Cases of 
 Rheumatism. 
 
 Acute and Subacute, 379 
 . 133 
 
 Subacute, 
 
 Acute, .... 246 
 
 Total Heart Disease. 
 
 187, or 1 in every 2-02 
 
 42, or 1 in every 3 11 
 14o, or 1 in every 169 
 
 Recent Heart Disease. 
 
 139, or 1 in every 272 
 
 20, or ♦ ill every 6 6.5 
 
 119, or 1 in every 2 06 
 
 Old-standing Heart 
 Disease.^ 
 
 48, or 1 in every 7 S9 
 
 22, or 1 in every 6-04 
 26, or 1 in every 9 46 
 
 1 It must be remarked that these numbers fall short of the truth in regard 
 to the amount of old-standing heart disease, inasmuch as the heart was previ- 
 ously affected to a greater or less extent in several of the cases in which recent 
 mischief occurred.
 
 240 STATISTICS OF HEART DISEASE 
 
 Thus, it would appear, that 26' in 145, or 1 in every 5*57 
 of the cases of heart affection met with in acute rheumatism, 
 are of oUl standing; 22' in 42, or 1 in every 1'9, of those ac- 
 companying the subacute form of the disease ; and 48^ in 187, 
 or 1 in every 3*89, of those discovered in acute and subacute 
 rheumatism, taken indiscriminately. 
 
 Taking these facts as the foundation of my calculations, I 
 find that those who have paid the closest attention to the subject, 
 agree very nearly in fixing upon one-half as about the propor- 
 tion of cases in which cardiac affection ordinarily arises in the 
 course of acute rheumatism. It occurred, as has been seen, in 
 about this proportion (119 to 246) among the patients admitted 
 into St. George's Hospital.' Dr. W. Budd met with it in about 
 one-half (21 in 43) of the cases which fell under his observa- 
 tion,^ and M. Bouillaud discovered it in about the same propor- 
 tion, (65 in 114.)^ Dr. Latham has reported cardiac affection 
 in nearly two-thirds (90 in 136) of his patients,* but as he 
 makes no mention of old-standing mischief, he probably includes 
 in his calculations all previously existing cardiac lesions. If, 
 then, in accordance with the results of my experience already 
 given, we suppose 16, or 1 in every 5*57, of Dr. Latham's cases 
 to have been of old standing, the proportion is reduced to 74 to 
 136, or to little more than that obtained by the authors before 
 referred to. Again, Dr. Taylor, of Huddersfield, reports 37 
 cases of heart affection among 75 of his rheumatic patients f 
 but as this number includes both recent and old-standing heart 
 disease, and is obtained from acute and subacute cases, taken 
 indiscriminately, it becomes necessary to subject both his num- 
 bers to correction before comparing them with the experience 
 of others. If, then, in accordance with the results already 
 given, we deduct 26, or rather more than one-third of his cases, 
 (1 in every 2-8) as subacute, and suppose nine and a half, or 1 
 in every 3*89, of his cases of heart affection to be of old stand- 
 
 * This number includes half the cases of uncertain date. 
 ^ "Library of Medicine," vol. v, p. 195. 
 
 * " Traile Clinique de Rheumatisme," Preface, p. 12. 
 
 * "Clinical Medicine," vol. i, p. 143. 
 
 * '• Med.-Chir. Trans.," vol. xxviii, p. 483.
 
 IN CONNECTION WITH RHEUMATISM. 
 
 241 
 
 inir, we find that 49 represents the number of cases of acute 
 rheumatism, and 27*5 the number of cases of recent heart affec- 
 tion, a result which tallies very closely with that which has 
 been obtained by other observers. The trifling differences 
 existing between the results of these various observations are 
 exhiliited in the following table :^ 
 
 Cases under the care of 
 the physicians at St. 
 George's Hospital . 
 
 Dr. Wm. Budd's cases 
 
 M. Bouillaud's cases . 
 
 Dr. Latham's cases . . 
 
 Dr. John Taylor's cases 
 Total . . . 
 
 Amount of rpcent 
 Heart Aflection. 
 
 Number of Cases 
 
 of Acute 
 
 Rheumatism. 
 
 Proportion of Cases in 
 which recent Heart 
 affection occurred. 
 
 119 
 21 
 65 
 T4 
 27-5 
 
 246 
 
 43 
 
 114 
 
 136 
 
 49 
 
 1 in every 2-06 
 1 " 2-04 
 1 " 1-75 
 1 " 1-83 
 1 " 1-78 
 
 306-5 
 
 588 
 
 1 " 1-91 
 
 A confirmation of these results is obtained by an examination 
 of eleven cases, of which I have collected notes, in which, from 
 the peculiar circumstances attending them, no regular medical 
 treatment was adopted. In six of these, prsecordial pain and 
 anguish were reported to have existed at the time of the attack, 
 and some evidence of unsoundness in the central organ of the 
 circulation was manifest when the patients came subsequently 
 under my notice. Two of these patients had previously 
 suffered from acute rheumatism, and therefore may have had a 
 murmur dating from, and referable to, their first attack : and in 
 some of the others, also, the murmur may have been due to 
 previous disease ; but the symptoms experienced in the attack 
 referred to, seem to show that the heart was then implicated in 
 the mischief. Therefore, although these cases afford data too 
 imperfect to form the groundwork of any accurate calculation 
 as to the frequency of carditis, they may serve, nevertheless, 
 to corroborate results obtained from more prolific sources. 
 
 I am thus induced to think that, under ordinary circum- 
 
 1 In the construction of this table I have omitted Dr. Macleod's cases, which 
 are inserted elsewhere, because he makes no mention of the frequency of endo- 
 cardial affection, and their quotation, therefore, would only lead to error. On 
 much the same grounds, no allusion is made to Dr. Basham's cases.
 
 242 STATISTICS OF HEART DISEASE 
 
 Stances, some heart aflfection arises in about half of all cases 
 of acute rheumatism ; but I am persuaded that, by judicious 
 treatment, this proportion may be very greatly reduced. 
 Among 168 cases which have come under my care since I first 
 commenced my present plan of treatment, the heart has been 
 implicated in 31 cases only, and in at least 26 of these the 
 afi'ection had commenced before I saw the patient. This fact 
 is almost sufficient of itself to afford decisive evidence on the 
 subject, and to show that, in most cases, the heart may be pro- 
 tected from mischief when the patient is early subjected to 
 appropriate treatment. But the evidence is even more con- 
 clusive if my earlier and less actively-treated cases are excluded 
 from the calculation. For among the last 126 cases in which 
 the heart remained free from inflammation at the time the 
 patients were first brought under my care, not a single case of 
 endocarditis or pericarditis has occurred, the heart having been 
 protected by the administration of remedies in the manner 
 already pointed out. 
 
 The frequency of pericarditis is a point on Avhich many 
 opposite conclusions have been arrived at ; the diff'erence, I 
 believe, resulting, as in the former instance, from the variety of 
 the grounds chosen as the basis of calculation. Dr. Macleod' 
 reports its occurrence in more than one-fifth (52 in 226, or 1 
 in every 4'3,) of his patients suffering from one variety of acute 
 rheumatism, and in about one-sixth (54 in 307, or 1 in every 
 5'7,) of those afilicted with the difi'erent varieties taken col- 
 lectively; Dr. Basham^ reports it in about one-fifth (14 in 66, 
 or 1 in every 4-7,) of those sufi'ering from acute articular rheu- 
 matism ; Dr. Latham^ in about one-sixth (22 in 136, or 1 in 
 
 ' On "Rheumatism," p. 154. 
 
 ^ " Medico-Chir. Trans.," vol. xxxii. Dr. Basham has reported 79 cases of 
 rheumatism, but several of these are cases of '' muscular" rheumatism, and one 
 is called decidedly " chronic muscular." In short, he has reported only 66 cases 
 of " acute arthritic" rheumatism. 
 
 8 "Clinical Medicine," vol. i, p. 144. Dr. Latham's numbers are 18 in 136, 
 but he reports 9 cases in which it was doubtful whether a murmur which ex- 
 isted was referable to pericardial or endocardial disease, and it is therefore 
 presumed, that 4 of these 9 doubtful cases were instances of pericarditis.
 
 IN CONNECTION WITH RHEUMATISM. 243 
 
 every 6-12 ;) Dr. Taylor^ in about one-sixth (8 in 49, or 1 in 
 every 64 ;) and I observed it in about the same proportion 
 (39 in 246, or 1 in every 6*3, ) among the cases of acute rheu- 
 matism admitted into St. George's Hospital. Dr. William 
 Budd^ met with it less frequently in his cases (5 in 43, or 1 in 
 every 8*6 ;) but I have some doubts whether the cases Dr. 
 Budd has recorded may not include examples of Avhat I have 
 termed " subacute" rheumatism, and if so, the disease probably 
 occurred in somewhat less than one-sixth of his acute cases 
 (5 in 28, or 1 in every 5'6.) 
 
 An equally striking uniformity is apparent in the result of 
 a strict examination into the frequency of recent endocardial 
 affection. It oc(!urred in 107 of the 246, or in 1 out of every 
 2*3 of the cases of acute rheumatism already quoted as forming 
 the basis of my calculations ;^ in 65 out of 136, or in 1 out of 
 every 2-09, of Dr. Latham's cases ;* in 17 "3 out of 43, or in 1 
 out of every 2-48, of Dr. William Budd's cases f and in 25*4 
 out of 49, or in 1 out of every 1*9, of Dr. Taylor's cases. ^ 
 
 A similar uniformity is also apparent in the result of an 
 
 1 " Mcdico-Chir. Trans.," vol. xxviii, p. 483. Di-. Taylor's numbers are 8 in 
 75; but he admits that subacute cases are included, and about one-third of the 
 entire number have therefore been deducted on that score. 
 
 2 " Library of Medicine," vol. v. 
 
 3 These 107 cases are made up thus: — 27 cases of endo-pericarditis ; 75 of 
 endocardial affection ; and 5, or half of the cases, in which the date of the 
 mischief was uncertain. (See Table II, pp. 254-5.) 
 
 * Dr. Latham reports 18 cases of exocardial, and 74 of endocardial affection, 
 and 9 in which the seat of the disease was doubtful. Assuming that 4 of these 
 doubtful cases were examples of exocardial disease, and 5 of endocardial affec- 
 tion, we get 22 cases of pericarditis, and 7'J of endocardial mischief. The 
 number 79, however, includes cases of old-standing cardiac lesions, and on 
 this score, therefore, we must deduct IG, or 1 in every 5-57 cases. Hence the 
 numbers given above. 
 
 5 Dr. Wm. Budd's numbers are 21 to 4.3, but as he makes no mention of 
 previously existing heart disease, it is assumed, in accordance with the results 
 already given, that 3 7, or 1 in every 5-57, of his cases were instances of old- 
 standing heart disease. Hence the numbers given above. 
 
 « Dr. Taylor's numbers are 34 to 75, but as the number 34 includes old- 
 standing heart disease, and the number 7.5 is obtained from acute and sub- 
 acute cases taken collectively, we must deduct 8-G, or 1 in every 389, of his 34 
 cases, as instances of old-standing disease, and 26, or 1 in every 2-8, of his 75 
 cases as subacute. Hence the numbers given ;ibove.
 
 244 
 
 STATISTICS OF HEART DISEASE 
 
 examination into the relative frequency of recent exocardial 
 and endocardial affection. Among the cases I have reported, 
 the former occurred in the proportion of 39 to 107, or of 1 to 
 every 2-7 of the latter;^ in Dr. Latham's cases,^ of 22 to 65, 
 or of 1 to every 2-9 ; in Dr. William Budd's,' of 5 to 17 "3, or 
 of 1 to every 3-4 ; and in Dr. Taylor's,^ of 8 to 25-4, or of 1 to 
 every 3-1. Dr. Macleod has not recorded any facts which 
 assist us in determining the relative frequenc}^ of exocardial 
 and endocardial disease ; and Dr. Basham has recorded only 
 7 instances of endocardial murmur among his 77 cases of 
 rheumatism, while among the same cases he has noted no less 
 than 14 instances of acute pericarditis. The proportion which 
 endocardial mischief is here made to bear to pericarditis, is so 
 utterly at variance with the experience of all other observers, 
 that it cannot be regarded as otherwise than exceptional, and 
 I have therefore abstained from classing Dr. Basham's cases 
 with the others. Possibly Dr. Basham, in the construction of 
 his table, may have limited his report in great measure to the 
 number of instances in which exocardial mischief was observed. 
 
 The results of these investigations are exhibited in the fol- 
 lowing tables : 
 
 Table I. — Pericarditis. 
 
 Cases und?r the physicians 
 at St. George's Hospital 
 Dr. Basham's cases . . . 
 Dr. Wiu. Budd's cases . . 
 Dr. Lathams cases . . . 
 Dr. Miicleod's cases . . . 
 Dr. Taylors cases . . . 
 
 Total 
 
 Number of Cases 
 of Pericarditis. 
 
 Number of Cases 
 
 of Acute 
 
 Rheumatism. 
 
 Proportion of Cases 
 iu which Peri- 
 carditis occurred. 
 
 39 
 14 
 
 5 
 22 
 54 
 
 8 
 
 246 
 
 66 
 
 43 
 
 136 
 
 307 
 
 49 
 
 1 in every 6-3 
 1 '• 4-7 
 I " 8-6 
 1 " 6-1 
 1 " 5-7 
 1 " 6-1 
 
 142 
 
 847 
 
 1 " 5-97 
 
 ' See Notes on preceding page.
 
 IN CONNECTION WITH RHEUMATISM. 
 
 Table II. — Recent Endocardial Affection. 
 
 245 
 
 Cases under the physicians 
 at St. George's Hospital 
 Dr. Wm. Budd's cases . . 
 Dr. Latham's cases . . . 
 Dr. Taylor's cases . . . 
 
 Total 
 
 Niimlier of Ca«es 
 of recent Eudo- 
 cardial affection. 
 
 Number of Cases 
 
 of Acute 
 
 Rheumatism. 
 
 Proporlion of Cases 
 
 in w)>ic{i recpat 
 Eudocai-dial affec- 
 tion occurred. 
 
 107 
 17-3 
 65 
 25-4 
 
 246 
 43 
 
 136 
 49 
 
 1 in every 2-29 
 1 " 2-48 
 1 " 2-09 
 1 " 1-92 
 
 214-7 
 
 474 
 
 1 " 2-25 
 
 Table III. 
 
 -Relative frequency of recent Exocardial and 
 Endocardial Affection. 
 
 Cases under the physicians 
 at St. George's Ho3pii;al 
 Dr. Wra. Budd's cases . . 
 Dr. Latham's cases . . . 
 Dr. Taylor's cases . . . 
 
 Total 
 
 Number of Cases 
 of Pericarditis. 
 
 Number of Cases 
 of recent Endo- 
 cardial affection. 
 
 Proportion which 
 recent Exncaidial 
 bears t" recent En- 
 docardial affection. 
 
 39 
 
 5 
 
 22 
 
 8 
 
 74 
 
 107 
 17-3 
 65 
 
 25-4 
 
 1 to every 2-7 
 1 •' 3-4 
 1 " 2-9 
 I " 3-1 
 
 214-7 
 
 1 " 2-9 
 
 The great excess in the frequency of endocardial aflFection 
 exhibited in these Tables, arises, I believe, not from the greater 
 frequency of endocarditis, but from the large number of cases 
 in -which a murmur is occasioned either by purely functional 
 causes, or by temporary imperfect closure of the mitial orifice 
 consequent on irregular contraction of the structures connected 
 with the valves, or by the presence of fibrin deposited on the 
 valves without the concurrence of endocardial inflammation. 
 Judging from my observation of the cases which I noted 
 during the period that I held the office of Medical Registrar, 
 as also of those which have fallen under my notice since my 
 appointment as one of the Physicians of St. George's Hospital, 
 I believe that somewhat less than one-third of all recent cardiac 
 murmurs met with among patients sufiering from acute rheu- 
 matism, will be found to result from pericarditis, and somewhat 
 more than one-third from endocarditis, while the remainder 
 will be referable to one of the three causes above specified as
 
 24G STATISTICS OF HEART DISEASE 
 
 contributing to tlie production of valvular murmur. This at 
 least is certain, that the existence of recent valvular murmur 
 was not accompanied by prgecordial pain, nor by any local 
 symptoms of inflammation, nor by any increase in the general 
 febrile symptoms, in more than 49 out of the 107 cases before 
 alluded to, and that the murmur ultimately subsided altogether 
 in many of the 58 cases in which no symptoms of inflammation 
 were observed. The exact number in which it ultimately dis- 
 appeared cannot of course be ascertained, but it had entirely 
 ceased in 23 before the patients left the hospital. 
 
 In strong contrast with these results, deduced from the 
 statistics of cases treated under the various methods usually 
 adopted, stands the evidence derivable from the records of th^ 
 alkaline mode of treatment, which I have employed ever since 
 the year 1845, and which I confidently introduced to the notice 
 of the Profession, in the first edition of this work, published 
 in the year 1852. Out of 168 patients whom I have treated 
 for acute rheumatism after the plan then recommended, only 
 31 have shown symptoms of cardiac inflammation, and of these 
 no less than 26 were afiected before I saw them, and 4 others 
 before they could be brought under the influence of the 
 remedies. In eight instances, simple pericarditis existed ; in 
 six others, pericarditis was complicated with recent endo- 
 carditis, and in the other seventeen, endocardial mischief was 
 present alone. Taking these figures as they stand, they show 
 pericarditis occurring once in every 12 cases, instead of in 
 every 5*93 cases ; and endocardial affection once in every 9*8 
 cases, instead of in every 2-25 cases; while, if we exclude 
 those instances in which cardiac disease had manifested itself 
 before the patient came under treatment, the pleasing fact 
 appears, that pericarditis occurred only once in every 84 cases, 
 and endocardial aff"ection once in every 56 cases. Nor is this 
 conclusion inconsistent with the experience of others. Several 
 medical gentlemen, who at my recommendation have adopted 
 the alkaline method of treatment, assure me that their patients 
 have enjoyed an equal immunity from heart aff"ection ; and Dr. 
 Garrod, who, since May, 1852, has been following a similar
 
 IN CONNECTION WITH RHEUMATISM. 247 
 
 line of practice, states that "in no case did affection of the 
 heart ensue after the patient had been more than forty-eight 
 hours under the influence of the medicine."^ Thus the state- 
 ments contained in the first edition of this work are confirmed 
 by the testimony of other observers, and it becomes apparent 
 that if the patient be seen early and treated judiciously, after 
 the method I was the first to recommend, rheumatic inflamma- 
 tion of the heart may be generally prevented. In short, the 
 conviction is forced upon us that this fearful disease — fearful, 
 Bot so much from the pain it causes, as from the damage it 
 inflicts on the central organ of circulation — may thus be 
 robbed of more than half its terrors. 
 
 But to return to the ordinary statsitics of heart disease in 
 connection with rheumatism. 
 
 That the age of the patient has a powerful influence in 
 determining the access of cardiac mischief, is sufficiently 
 apparent from the Tables appended to this chapter, for it will 
 be observed^ that no less than 114 out of the 130 cas^s of recent 
 heart aff"ection before referred to occurred in patients under 
 the age of 30. In the production of exocardial inflammation 
 alone, its influence is even more apparent ; for 23 out of 41 
 instances, or above one-half, were met with in patients who did 
 not exceed the age of 20, and 37 out of the 41, in patients 
 under the age of 30, while 4 only out of the whole number ex- 
 ceeded that age. Nor has the influence of age been less strik- 
 ingly displayed in the cases observed by others. Drs. Rilliet 
 and Barthez'^ report pericarditis in more than one-third (4 in 
 11) of their rheumatic children patients. Dr. Macleod noted 
 its occurrence in exactly one-half (4 in 8) of his children 
 patients;' and of Dr. Taylor's, " 15 patients having rheumatic 
 pericarditis, nine, or two-thirds, were 20 years old, or under; 
 five between 20 and 26 years ; and the remaining one only 
 was above 40 years of age."'^ 
 
 1 "Med.-Chir. Trans.," vol. xxxviii, p. 151. 
 
 2 See Table I, pp. 253-54. 
 
 ' ''Traite Clinique et Pratique des Maladies des Enfants," vol. i, p. 210. 
 
 < On " Rheumatism," pp. 15G-7. 
 
 ° " Medico-Chir. Trans.," vol. xxviii, p. 528.
 
 248 STATISTICS OF HEART DISEASE 
 
 This proneness to heart disease, and more especially to 
 inflammation of the pericardium, which thus appears to attach 
 to youth, might be supposed explicable by the frequent occur- 
 rence of acute rheumatism in persons of tender years. But 
 the Tables show^ that this will not serve to clear up the mys- 
 tery, for although acute rheumatism is certainly most common 
 in early life, yet the relative frequency of pericarditis is found 
 to vary in tolerably exact proportion to the age of the sufferer. 
 Thus, it occurred in rather more than one-third (8 in 22, or 1 
 in every 2*75,) of all below the age of 15 ; in less than one-fifth 
 (15 in 82, or 1 in every 5-4,) of those between the ages of 15 
 and 20 ; and in less than one-tenth (9 in 92, or 1 in every 
 10-2,) of those between the ages of 20 and 25 ; while, above 
 the age of 25, the proportion of cases in which it occurred, 
 diminishes with even greater rapidity. The more probable 
 explanation is that which I have offered in another chapter,^ 
 viz., that in youth the heart is extremely irritable, and there- 
 fore specially prone to suffer from any disturbing influence. 
 
 Whether sex may influence the production of heart disease 
 in connection with rheumatism, is a question on which we have 
 hardly enough facts to warrant our drawing any positive con- 
 clusions. The Tables I have given,^ however, show that some 
 recent cardiac mischief was observed in 1 out of every 3"1 
 men (71 in 223,) and in 1 out of every 2-2 women (68 in 156 ;) 
 that pericarditis occurred once in every 12-4 men, and in 1 out 
 of every 6*7 women; or taking "acute rheumatism" alone, in 
 1 out of every 7'7 men, and in 1 out of every 5*2 women ; and 
 that recent endocardial affection occurred in 1 out of every 3-4 
 men, and in 1 out of every 2-6 women; or taking acute rheu- 
 matism alone, in 1 out of every 2-4 men, and in 1 out of every 
 2-1 women. It would thus appear that heart disease is more 
 common among women than among men, a circumstance which 
 
 1 See Tables, pp. 253-6. 
 
 2 Cap. VI, pp. 141-3. 
 
 3 See Tables appended to this chapter, pp. 253-4. The numbers 71 and 68 
 include half the cases of uncertain date.
 
 IN CONNECTION WITH RHEUMATISM. 249 
 
 accords completely with the experience of Dr. Macleod,' and 
 with the more recent observations of my successor, Dr. Bar- 
 clay.^ If the extraordinary proneness to heart disease, engen- 
 dered by youth, be attributable, as I believe it to be, to the 
 greater irritability of the heart at that age, it is probable that 
 the fact of the heart being usually more irritable in women 
 than in men, may be the reason of its being more commonly 
 affected in the one case than in the other. Thus this circum- 
 stance, if verified by more extended observations, may serve 
 as another link in the chain of evidence adduced to show how 
 closely the occurrence of cardiac inflammation is connected 
 with the heart's irritability. 
 
 The form which the articular symptoms assume is obviously 
 connected more or less closely with the frequency of cardiac 
 affection, and affords a tolerable criterion as to the probability 
 of its occurrence. Whether owing to the age and strength of 
 the patient, or in consequence of some obscure constitutional 
 peculiarity, most certain it is that the fibrinous structures are 
 peculiarly apt to suffer in youth, and the synovial membranes 
 in more advanced age, and that the occurrence of heart affec- 
 tion is allied most closely to the former variety of articular 
 inflammation. Of the 52 cases of pericarditis reported by Dr. 
 Macleod, no less than 50 occurred among patients in whom 
 the fibrinous symptoms were strongly marked f Dr. Taylor's 
 instances all occurred in the same class of cases ;* and so did 
 all the 41, save 3, to which I have already referred. I would 
 not, however, be misunderstood on this subject. In acute 
 rheumatism the fibrous and the synovial symptoms are usually 
 more or less intimately blended, the fibrous symptoms predom- 
 inating at one period of the attack, the synovial symptoms at 
 
 1 Dr. Macleod reports '• of the total number of patients laboring under acute 
 rbeumalism, 1.37 were males, and 8'J females. Of the former '18. and of the 
 latter 24, had symptoms of pericarditis ; or of the men, rather less than 1 in o, 
 and of the women, rather more than 1 in 4." (On " Rheumatism," p. 154.) 
 
 2 See " Lancet" for July 26th, 1851, and " Medico-Chir. Trans.," vol. xxx. 
 p. 18. 
 
 * On " Rheumatism," p. 113. 
 
 * " Medico-Chir. Trans.," vol. xxviii, p. 522. 
 
 17
 
 250 STATISTICS OF HEART DISEASE 
 
 another ; and it has been already stated, that no difference 
 exists between those cases in which the fibrous symptoms are 
 most developed and those in which the synovial symptoms are 
 more prominent, beyond that which is impressed upon them by 
 peculiarities of age, sex, constitution, and the like. The former, 
 however, are those which chiefly occur in youth, and are marked 
 by the greatest amount of febrile disturbance, and are there- 
 fore the very cases which are especially prone to the invasion 
 of pericarditis. Synovial effusion is not necessarily absent, 
 but the fibrous symptoms are most conspicuous. I am not aware 
 that the same relationship has been traced between fibrous 
 rheumatism and endocardial inflammation ; nor, indeed, can 
 such a relationship be discovered, if all endocardial murmurs 
 are to be taken as indications of existing endocarditis. But 
 close observation has led me to believe that it exists in an 
 equally striking degree ; and that all efforts to trace it have 
 proved ineffectual, simply because forms of cardiac affection 
 which may of course coexist with any form of rheumatism, such, 
 for instance, as old-standing valvular disease, and functional 
 murmurs in no way referable to cardiac inflammation, have 
 been included among the cases which have formed the subject 
 of investigation. When these are excluded, the connection will 
 always be apparent and striking. Of the 107 instances of 
 recent endocardial affection observed in connection with acute 
 rheumatism, 58, as already stated, were unaccompanied by any 
 local or general symptoms of cardiac inflammation, and many 
 of these occurred in patients in whom synovitis was a promi- 
 nent feature. But of the 49 which did present undoubted evi- 
 dence of cardiac inflammation, no less than 42 occurred in 
 cases in which fibrous symptoms were strongly developed. 
 
 As to the exact period of the attack at which heart affection 
 most commonly arises I am not able to speak with certainty, 
 nor indeed can I conceive that under any circumstances the 
 information obtained at large public institutions can give us 
 more than an approximation to the truth. For, judging from 
 my own observation, nearly half the instances of recent cardiac 
 affection commence before the patient's admission into the hos-
 
 IN CONNECTION WITH RHEUMATISM. 251 
 
 pital, and therefore before it is possible to obtain any accurate 
 information as to the date of the mischief ; and if such cases 
 are to be excluded from the calculation, the results cannot be 
 otherwise than erroneous. The facts I have obtained, however, 
 stand thus. Inflammation of the heart occasionally shows 
 itself as the first and for some time the only local symptom of 
 rheumatism ;^ more commonly it arises between the second and 
 the twentieth day of the attack, and sometimes, when the 
 rheumatism is obstinate and lingering, does not supervene 
 until the twenty-fourth day, or even a later period. In most 
 instances it arises when the fever is at its height. 
 
 Of the 41 cases of pericarditis already so often referred to, 
 19, at the date of their admission into the hospital, gave evi- 
 dence of existing cardiac inflammation. On the average, peri- 
 carditis had commenced in these cases before the seventh day 
 of the attack. Of the remaining 22 — 
 
 2 occurred on the fifth day of the rheumatic fever. 
 5 " sixth " 
 
 4 " seventh " 
 
 5 " eighth " 
 2 " tenth " 
 
 2 " twelfth " 
 1 " seventeenth " 
 1 " twenty-fourth " 
 
 Of the 126 instances of recent endocardial affection noted 
 during the same period, 53 existed at the time of the patient's 
 admission into the hospital ; in 17 of the other 73, in which a 
 murmur was not developed until after the patient's admission, 
 I have no note to enable me to determine the exact date of the 
 mischief; but of the remaining 56 — 
 
 1 occurred on the third day of the rheumatic fever. 
 
 3 " fourth '• 
 
 2 " fifth " 
 15 between the sixth and the tenth days. 
 13 " tenth and the fifteenth days. 
 
 11 " fifteenth and the twentieth days. 
 
 5 " twentieth and the twenty-fifth days. 
 
 G after that date. 
 
 1 I have met with five instances in which the heart was aficcted for some 
 time prior to the development of articular symptoms ; but none of these 
 occurred among the cases which are included in the present calculation.
 
 262 STATISTICS OF HEART DISEASE 
 
 Dr. William Budd reports the occurrence of cardiac affec- 
 tions as most common bet"\veen the eighth and the twenty- 
 seventh day of the rheumatic attack ;^ but Dr. Taylor, who 
 speaks from his observation of 15 cases, says heart affection 
 occurs in fully one-half of the cases before the fourth day of 
 the disease.^ 
 
 Whether a predisposition to affection of the heart may not 
 be engendered by the occurrence of a previous attack of peri- 
 carditis or endocarditis is a question on which I have hardly 
 sufficient data to enable me to speak with confidence. Theo- 
 retically it is certain that the occurrence of cardiac inflamma- 
 tion must forever after render the heart more than ordinarily 
 liable to be affected, on the same principle that a joint which 
 has been strained or injured is afterward peculiarly suscepti- 
 ble of morbid influences ; and it is equally certain that, as far 
 as they go, the ascertained facts corroborate this view, for 
 they show that the heart is less liable to suffer in primary 
 invasions of rheumatism than in cases where there has been a 
 previous attack, and where, therefore, the heart may have 
 been previously implicated. Of the 246 cases of acute rheu- 
 matism already referred to, 138 were instances of a first 
 attack, 84 were cases in which there had been one or more 
 previous attacks, and 24 were cases in which, either from my 
 inability to obtain the requisite information, or from some 
 other cause, I have made no note on the subject. Among 
 the cases which form the first of these classes, there occurred 
 only 59 examples of heart complications, while there were no 
 less than 48 in the second ; in other words, some recent heart 
 disease occurred in 41*8 per cent, of the first attacks, and in 
 55*8 of the subsequent attacks.^ 
 
 1 " Library of Medicine," vol. v, p. 195. 
 
 - " Medico-Chir. Trans.," vol. xxviii. 
 
 * The statistics drawn up by Dr Barclay, my successor as Medical Regis- 
 trar of St. George's Hospital, from his observation of the cases admitted dur- 
 ing the two years ending Dec. 31st, 1850, show that cardiac complication 
 occurred 18 or 20 per cent, more frequently in subsequent rheumatic attacks 
 than in primary ones. For further details on this subject, see •• Med.-Chir. 
 Trans.." vol. xxxv, p. 18.
 
 IN CONNECTION WITH RHEUMATISM. 253 
 
 But although these facts exhibit a lesser tendency to heart 
 aifection in primary than in subsequent attacks of acute rheu- 
 matism, the proportions are altogether changed when those 
 cases only are examined in which there is unequivocal evidence 
 of true cardiac inflammation. Thus, of the 49 cases of peri- 
 carditis which were met with in the class of acute rheumatism, 
 25 occurred in primary and 14 only in subsequent attacks, 
 and in several of these 14 there was a tolerably distinct his- 
 tory of the heart having been implicated during the former 
 invasion of rheumatism. Taking the figures as they stand, 
 however, they exhibit jaericarditis occurring in 18*1 per cent, 
 of the primary and in 16-6 only of the subsequent attacks, and 
 afford one among many presumptive proofs that a large pro- 
 portion of the endocardial murmurs which arise during the 
 course of acute rheumatism, are not attributable to true in- 
 flammation. 
 
 Table I. 
 
 Abstract of Cases of Acute and Subacute Rheumatism^ admitted into St. George's 
 Hospital, between the 1st of January, 1845, and the 1st of May, 1848, showing 
 the number which were complicated by disease of the Heart ; the Age and Sex of 
 the Patients in whom it occurred, the form which it assumed, and the proportion 
 in which each form occurred among the tivo Sexes. 
 
 Total number of Cases, 379. Of which, 223 occurred ia men, and 15(3 in 
 
 women. 
 Heart affected in 187 instances. Healthy in IGO instances. Not noted in 32. 
 Of the 187 instances of Heart affection, 130 were cases in which the disease 
 
 was of recent origin. 
 " " 39 were cases in which the disease 
 
 was of old standing. 
 " " 18 were cases in which the disease 
 
 was of uncertain date. 
 Of the 130 cases of recent Heart disease, 13 were instances of Pericarditis 
 
 alone. 
 " " 28 Avere instances of Endo-pericar- 
 
 ditis. 
 " " 89 were instances of Endocardial 
 
 affection alone. 
 The 18 cases of uncertain date were all instances of Endocardial disease. 
 Of the 13 cases of Pericarditis, G occurred in men, and 7 in women.
 
 254 
 
 STATISTICS OF HEART DISEASE 
 
 Of the 28 cases of Endo-'pericarditis, 12 occurred iu men, and 16 in women. 
 " 89 " recent Endocardial affection, 48 occurred in men, and 41 in 
 
 women. 
 " 39 " old-standing disease, 23 occurred in men, and 16 in women. 
 " 18 " uncertain date, 10 occurred in men, and 8 in women. 
 Pericarditis then occurred once in every 12-4 men, and once in every 6-7 
 
 women. 
 Recent Endocardial affection once in every 3-4 men, and once in every 2-G 
 
 women. 
 Old-standing Heart disease once in every 7-9 men, and once in every 7-8 
 women. 
 
 
 <i> to . 
 
 Ill 
 
 oi 
 
 i 
 
 4 
 
 o 6 
 
 1^ 
 
 -standing 
 ular and 
 aps Exo- 
 ial Disease. 
 
 (5 a 
 
 
 o = E 
 
 _ 3 
 
 II 
 
 1 
 
 
 
 a . 
 
 Sew2 
 
 a •« 
 
 
 a>r3 S 
 
 te 
 
 ® 
 
 
 o? o 
 
 •B > .g-O 
 
 > ® a 
 
 
 o3 -* £i 
 
 
 e^ 
 
 (2 
 
 SS.2 
 
 o "3 2 S 
 
 "3 «'S 
 
 Under 15 
 
 o -'-' 
 
 '~' 
 
 
 
 K "- 
 
 ^=.. 
 
 K.O.- 
 
 22 
 
 12 
 
 3 
 
 5 
 
 3 
 
 
 
 1 
 
 15 to 20 
 
 82 
 
 49 
 
 4 
 
 11 
 
 26 
 
 4 
 
 4 
 
 20—25 
 
 92 
 
 49 
 
 3 
 
 6 
 
 26 
 
 9 
 
 5 
 
 25—30 
 
 79 
 
 41 
 
 1 
 
 4 
 
 22 
 
 9 
 
 5 
 
 30—35 
 
 40 
 
 14 
 
 1 
 
 1 
 
 4 
 
 6 
 
 2 
 
 35—40 
 
 28 
 
 12 
 
 — 
 
 1 
 
 4 
 
 6 
 
 1 
 
 40—45 
 
 15 
 
 5 
 
 1 
 
 — 
 
 2 
 
 2 
 
 — 
 
 45—50 
 
 14 
 
 4 
 
 — 
 
 — 
 
 2 
 
 2 
 
 — 
 
 50—55 
 
 3 
 
 — 
 
 — 
 
 — 
 
 — 
 
 — 
 
 — 
 
 55—60 
 
 4 
 
 1 
 
 — 
 
 — 
 
 — 
 
 1 
 
 — 
 
 379 
 
 187 
 
 13 
 
 28 
 
 89 
 
 39 
 
 18 
 
 Table II. 
 
 Abstract of Cases of Acute RheumatKtn, admitted into St. George's Hospital^ from 
 January \st, 1845, to May \st, 1848, shotving the number which were compli- 
 cated by Heart Disease ; the Age and Sex of the Patients in whom it occurred, 
 the form which it assumed, and the proportion in which each form occurred 
 among the two Sexes. 
 
 Total number of Cases, 246. Of which 131 occurred in men, and 115 in 
 
 women. 
 Heart affected in 145 instances. Healthy in 93 instances. Not noted, and 
 
 therefore probably healthy in 8. 
 Of the 145 instances of Heart affection, 114 were cases in which the disease 
 
 was of recent origin. 
 " " " 21 were cases in which the disease 
 
 was of old standing. 
 " " " 10 were cases in which the date of 
 
 the disease was uncertain. 
 Of the 114 cases of recent Heart disease, 12 were cases of Pericarditis alone.
 
 IN CONNECTION WITH RHEUMATISM. 
 
 255 
 
 Of the 114 cases of recent Heart disease, 27 were case^of Endo-pericarditis. 
 
 " " " 75 were cases of Endocardial affection 
 
 alone. 
 The 10 cases of uncertain date were all instances of Endocardial disease. 
 Of the 12 cases of Pericarditis, 5 occurred in men, and 7 in women. 
 
 " 27 " Endo-pericarditis, 12 occurred in men, and 15 in women. 
 " 75 " Recent Endocardial aftection, 39 occurred in men, and 36 
 
 in women. 
 " 21 " Old-standing disease, 11 occurred in men, and 10 in women. 
 " 10 " uncertain date, G occurred in men, and 4 in women. 
 Pericarditis then occurred once in every 7-7 men, and once in every 5-2 women. 
 Recent Endocardial aflection once in every 2-4 men, and once in every 2-1 
 
 women. 
 Old-standing Heart affection once in every 9-3 men, and once in every 9-5 
 women. 
 
 
 <c 
 
 6 
 
 
 
 o i 
 
 tc-^ii 
 
 ^ i 
 
 
 li 
 
 o a 
 
 
 ci 
 
 
 •si . 
 
 3 =^ X ^ 
 
 f a oi.5 
 
 
 
 J« 
 
 
 
 
 a) :S.2 
 
 ■3>f.V. 
 
 t> <B - 
 
 ■5 *'3 
 
 Under 15 
 
 K 
 
 Ph 
 
 
 K "- 
 
 > o-» 
 
 t>®- 
 
 15 
 
 9 
 
 2 
 
 5 
 
 2 
 
 
 
 
 
 15 to 20 
 
 58 
 
 37 
 
 4 
 
 10 
 
 21 
 
 1 
 
 1 
 
 20—25 
 
 63 
 
 39 
 
 3 
 
 6 
 
 22 
 
 5 
 
 3 
 
 25—30 
 
 50 
 
 33 
 
 1 
 
 4 
 
 20 
 
 4 
 
 4 
 
 30—35 
 
 22 
 
 11 
 
 1 
 
 1 
 
 4 
 
 4 
 
 1 
 
 35—40 
 
 17 
 
 8 
 
 — 
 
 1 
 
 3 
 
 3 
 
 1 
 
 40—45 
 
 9 
 
 4 
 
 1 
 
 — 
 
 1 
 
 2 
 
 — 
 
 45—50 
 
 9 
 
 3 
 
 — 
 
 — 
 
 2 
 
 1 
 
 — 
 
 50—55 
 
 1 
 
 — 
 
 — 
 
 — 
 
 — 
 
 — 
 
 — 
 
 55— GO 
 
 2 
 
 1 
 
 — 
 
 — 
 
 — 
 
 1 
 
 — 
 
 246 
 
 145 
 
 12 
 
 27 
 
 75 
 
 21 
 
 10 
 
 Table III. 
 
 Abstract of Cases of Subacute Rheumatism, admitted into St. Georffe's Hospital, 
 between the 1st of January, 1845, and the \st of May, 1848, shoiving the number 
 complicated by Heart disease ; the Age. and Sex of the Patients in whom it 
 occurred, the form which it assumed, and the proportion in ivhich each form 
 occurred among the two Sexes. 
 
 Total number of Cases, 133. Of which 92 occurred in men, and 41 in women. 
 Heart affected in 42 instances. Healthy in 67 instances. Not noted in 24. 
 Of the 42 instances of Heart affection, 16 were cases in which the disease was 
 
 of recent origin. 
 " " " 18 were cases in which the disease was 
 
 of old standing. 
 " " " 8 were cases in which the date of the 
 
 disease was uncertain.
 
 256 
 
 STATISTICS OF HEART DISEASE. 
 
 Of the IG cases of recerrt Heart disease, 1 was a case of Pericarditis alone. 
 " " " 1 was a case of Endo-pericarditis. 
 
 " " " 14 were cases of Endocardial affection 
 
 alone. 
 The 8 cases of uncertain date were all instances of Endocardial disease. 
 The 1 case of Pericarditis occurred in a man. 
 The 1 case of Endo-pericarditis occurred in a woman. 
 
 Of the 14 cases of recent Endocardial affection, 9 occurred in men, and 5 in 
 women. 
 " 18 " old-standing disease, 12 occurred in men, and () in women. 
 " 8 " uncertain date, 4 occurred in men, and 4 in women. 
 Pericarditis then occurred once in every 92 men, and once in every 41 women; 
 or in little more than 1 per cent, among the men, and i per cent, among 
 the women. 
 Recent Endocardial affection occurred once in every 8-3 men, and once in 
 
 every 5-1 women. 
 Old-standing Heart disease occurred once in every 6-5 men, and once in every 
 5-1 women. 
 
 
 ^ 3 
 
 6 
 
 
 
 o a 
 
 tc-S o S 
 
 m t< 
 
 
 ^« . 
 
 GO ® -2 
 
 •3- 
 
 
 
 
 -standin 
 ular at 
 aps Ex 
 ial Disea 
 
 5| 
 
 3 =-0 
 
 
 
 cd 
 
 
 o 
 
 »■? rt 
 
 •O > J=T3 
 
 > » d 
 
 Under 15 
 
 % ^ cS 
 
 tS 
 
 I 
 
 Ph 
 
 S 3.2 
 
 sgll 
 
 |rs 
 
 7 
 
 3 
 
 1 
 
 
 
 1 
 
 — 
 
 1 
 
 15 to 20 
 
 24 
 
 12 
 
 — 
 
 1 
 
 5 
 
 3 
 
 3 
 
 20—25 
 
 29 
 
 10 
 
 — 
 
 — 
 
 4 
 
 4 
 
 2 
 
 2.5—30 
 
 29 
 
 8 
 
 — 
 
 
 
 2 
 
 5 
 
 1 
 
 30—35 
 
 18 
 
 3 
 
 — 
 
 — 
 
 — , 
 
 2 
 
 1 
 
 35—40 
 
 11 
 
 4 
 
 — 
 
 — 
 
 1 
 
 3 
 
 — 
 
 40—45 
 
 6 
 
 1 
 
 — 
 
 — 
 
 1 
 
 — 
 
 — 
 
 45—50 
 50—55 
 55—60 
 
 5 
 2 
 2 
 
 1 
 
 — 
 
 — 
 
 — 
 
 1 
 
 — 
 
 — 
 
 — 
 
 — 
 
 — 
 
 — 
 
 — 
 
 133 
 
 42 
 
 1 
 
 1 
 
 14 
 
 18 
 
 8
 
 CHAPTER X. 
 
 ON AFFECTIONS OF THE BRAIN, INFLAMMATION OF THE 
 LUNGS AND PLEUR.E, AND DISORGANIZATION OF THE 
 JOINTS. 
 
 Although inflammation of the membranes of the heart is by 
 far the most common complication of acute rheumatism, yet do 
 we sometimes meet with symptoms indicative of derangement 
 in other organs. Among these, the most formidable are sug- 
 gestive of disorder of the cerebral structures. A patient, for 
 instance, who for a week or ten days has been suffering from 
 acute rheumatism, and has presented no untoward symptom, 
 after passing one or two restless nights becomes strange and 
 flighty in his manner, complains, perhaps, of headache, and is 
 shortly seized with furious delirium, during which he appears 
 to be insensible to pain, and moves his limbs in utter disregard 
 of his inflamed and exquisitely painful joints. And then, if he 
 does not shortly improve, he either dies of exhaustion or falls 
 into a state of profound coma, and expires in the course of a 
 few hours. ^ 
 
 Symptoms such as these were formerly referred to inflamma- 
 tion of the brain or its meninges, and the unfortunate sufferer 
 was bled from the arm, or leeched on the temples, and subjected 
 to such other antiphlogistic treatment as appeared called for 
 by the urgency of the supposed cerebral symptoms.^ But 
 pathological research has at length discovered that cerebral 
 disturbance is not always symptomatic of cerebral inflammation, 
 and that a patient suffering from acute rheumatism may pass 
 into a state of violent delirium, and die comatose or convulsed, 
 
 1 Some of these cases are characterized from the first by a strange wayward- 
 ness and taciturnity. 
 
 2 For an illustration of this fact, consult the record of a case reported by 
 Mr. Stanley, in the seventh volume of the " Medico-Chir. Trans."
 
 258 AFFECTIONS OF THE BRAIN 
 
 although on dissection neither the brain nor its membranes 
 present the slightest trace of inflammatory action. Nay, more, 
 it has been proved beyond dispute, that although in some rare 
 instances the symptoms alluded to do indicate inflammation of 
 the brain or its meninges, yet that such is very rarely the case ; 
 that, more generally, they are coincident with inflammatory 
 action about the heart, and are unconnected with any cerebral 
 lesion ; not unfrequently accompany pleuritis or pneumonia ; 
 and occasionally present themselves to an alarming extent, 
 when neither the brain, nor the heart, nor the lungs are 
 afiected. 
 
 The question, therefore, naturally suggests itself, — to what 
 are these cerebral symptoms attributable ? Are they to be 
 regarded as tokens of threatening mischief within the cranium ? 
 or as evidences of the lighting up of some distant internal local 
 inflammation ? or as expressions of alarm experienced by the 
 system generally, and by the sensorium, the source of the 
 system's consciousness, at the interference with its nutrition 
 resulting from the poisoned condition of the blood ? 
 
 To me I confess the latter appears the only satisfactory 
 explanation. 
 
 At one time all cerebral symptoms which occurred in the 
 course of acute rheumatism were referred to inflammation of the 
 brain or its membranes, resulting, as was supposed, from 
 metastasis of the morbid action to the cerebral structures, in 
 consequence of the subsidence of articular inflammation. But 
 their independence of metastatic action is attested, by their not 
 unfrequent occurrence without the subsidence of articular 
 inflammation ; and their independence of mischief developed 
 within the cranium is abundantly proved by dissection after 
 death, which, even when the case has terminated fatally, fails 
 utterly, in most cases, in affording the slightest evidence of 
 cerebral mischief.* 
 
 « 
 
 1 In proof of this, I would refer to the case recorded at pp. 275-6 of this 
 Treatise, as also to the valuable cases reported by Dr. Richard Bright, in his 
 account of spasmodic diseases accompanying affections of the pericardium ; by 
 Dr. George Burrows, in his worii on " Disorders of the Cerebral Circulation ;"
 
 AS CONSEQUENCES OF ACUTE RHEUMATISM. iJ59 
 
 The second sugo-estiGn is more in accordance with sound 
 pathology, but nevertheless is not quite satisfactory. Soon after 
 the discovery that cerebral disturbance may arise in the course 
 of acute rheumatism, without the concurrence of cerebral 
 inflammation, delirium was so often found associated with 
 active cardiac disease, that many persons were led to regard 
 disorder of the sensorial functions as invariably connected with 
 mischief occurring in the central organ of the circulation. The 
 old-fashioned doctrine of metastasis to the brain exploded under 
 the influence of pathological research, and the heart was in 
 every case pronounced to be the "fons et origo malorum." By 
 some, its anatomical relations with the cerebrum were pointed 
 to, in explanation of the symptoms observed, and the delirium 
 was attributed to irritation conveyed to the brain by the phrenic^ 
 and pneumogastric^ nerves, as a consequence of inflammation 
 of the pericardium or endocardium. By others, however, sym- 
 pathetic irritation was considered inadequate to explain the 
 symptoms, which were therefore attributed to disturbance of 
 the cerebral circulation, occasioned by the embarrassment of 
 the heart's action, which results from the access of cardiac 
 inflammation.^ But neither of these interpretations appears to 
 me correct, inasmuch as delirium, convulsions, and coma are 
 always rare and exceptional phenomena, even when carditis 
 terminates fatally ; not unfrequently arise in cases distinguished 
 by less than the average severity of their cardiac symptoms, 
 and in which, therefore, presumption favors the belief, that 
 there is no unusual irritation of the cardiac nerves ; and occur 
 sometimes when dissection after death proves the heart and its 
 membranes to be quite free from disease, and Avhen, therefore, 
 
 by Dr. Latham, in his work on "Clinical Medicine;" by Dr. Todd, in his 
 Lumleian Lectures ; and by Dr. Watson, in his " Practice of Physic." Andral, 
 Bouillaud, Davis, Rostan, Stanley, and others, have reported similar symptoms 
 connected with pericarditis, when occurring without any accompanying rheu- 
 matism. 
 
 1 Dr. R. Bright and M. Bouillaud. 
 
 2 Dr. Hope, op. cit. 
 
 3 Dr. Watson's " Practice of Physic," ed. 1, vol. ii, p. 276; and Dr. Burrows 
 on "Disorders of the Cerebral Circulation," p. 212.
 
 260 AFFECTIONS OF THE BRAIN 
 
 the non-existence of such a cause of irritation is placed beyond 
 all doubt.^ 
 
 The same observations apply -with equal if not greater force, 
 to those instances in which cerebral symptoms are coincident 
 ■with inflammation of the respiratory organs. That consider- 
 able disturbance of the sensorial functions is sometimes associ- 
 ated with pleurisy and pneumonia when occurring in the course 
 of acute rheumatism, is a fact familiar to all practical men, nor 
 can it admit of question, that such a complication must inter- 
 fere materially with the maintenance of a due circulation 
 through the brain. But equally certain is it, that extensive 
 mischief may take place in the lungs, or within the cavities of 
 the pleurre, unattended by any symptoms, however slight, of 
 cerebral disturbance ; and, on the other hand, that delirium of 
 a most violent character may be, and frequently is met with, 
 unaccompanied by any evidence, either general or physical, of 
 pulmonary inflammation. So, even admitting that carditis and 
 pleuro-pneumonia do exercise some influence in producing 
 cerebral disturbance, they can be regarded only as occasional 
 and accessory causes. 
 
 It is far different, however, in regard to the third suggested 
 cause of rheumatic delirium. The blood, in every case of rheu- 
 matism, is poisoned by the presence of morbific matter, and the 
 nutrition of the brain is interfered with in consequence ; and 
 although delirium, convulsions, and coma may result in turn 
 from cerebro-spinal inflammation, yet an altered condition of 
 the circulating fluid is equally, if not more energetic in their 
 production.^ Every one, for instance, knows how certainly 
 
 1 In a review of the first edition of this work, it was suggested that the 
 detachment of fibrinous vegetations from the valves on the left side of the 
 heart, and their impaction in the vessels supplying the brain, may be the cause 
 of cerebral disturbance in these cases. This supposition, however, is simply 
 gratuitous, and without foundation. In the valuable records of fibrinous plug- 
 ging of the cerebral vessels, published by Dr. Kirkes, in vol. xxxv of the 
 " Medico-Chirurgical Transactions," hemiplegia, and not delirium, resulted 
 
 rom the cause alluded to ; and extensive softening of the cerebral structure was 
 the characteristic pathological phenomenon — results totally unlike those which 
 are met with in connection with rheumatic delirium. 
 
 2 For full and copious illustrations of this important fact, see Dr. Todd's 
 Lumleian Lectures for 1850.
 
 AS CONSEQUENCES OF ACUTE RHEUMATISM. 261 
 
 excitement or profound coma is caused by the ingestion of 
 inordinate quantities of spirituous liquors, and by the action of 
 belladonna and other poisonous agents ; how frequently delirium 
 results from the deleterious influence of urea, and how often it 
 accompanies typhus fever, erysipelas, and almost every exanthe- 
 matous disorder. Yet, in all these cases, dissection after death 
 has shown that such symptoms afford not the slightest ground 
 for the presumption of cerebral congestion or cerebral inflam- 
 mation. The brain has been found paler and drier than usual, 
 or of a darker color, and marked by an increased number of 
 bloody puncta, and sometimes a small quantity of serum has 
 been discovered under the pia mater or in the ventricles, as the 
 result of a retarded cerebral circulation. Rarely, however, 
 has there been any trace of inflammatory action, or of any other 
 organic lesion. In fact, experience has shown, that whenever 
 the blood is poisoned, or altered in character, as it is in all the 
 cases referred to, there may occur, without any local inflamma- 
 tion, every shade and variety of cerebral disturbance, from 
 slight wandering or flightiness to violent maniacal delirium, 
 accompanied or unaccompanied by convulsions, or tetanic 
 spasms, and terminating in recovery, or in death by coma. 
 
 A distempered condition of the blood, then, I conceive to be 
 the true proximate cause of the sensorial disturbance occasion- 
 ally observed in the course of acute rheumatism.^ For while 
 we find acute rheumatism attended by every species of delirium, 
 and every variety of spasmodic action, we find almost invari- 
 ably, as in the cases just alluded to, a total absence of morbid 
 appearances within the cranium or the spinal cord, capable of 
 accounting for the cerebral or cerebro-spinal disturbance. And 
 although this disturbance is sometimes associated with inflam- 
 mation in other organs, yet instances are not wanting in which 
 delirium, by taking place without the concurrence of any 
 
 ^ Dr. Todd has urged this view most closely and forcibly in bis admirable 
 Lectures on Delirium and Coma, delivered before the Royal College of Physi- 
 cians, but he does not appear to have dwelt sufficiently on the causes which 
 give effect to the operation of the poison in certain cases, and which by iheir 
 absence prevent cerebral disturbance in others.
 
 262 AFFECTIONS OF THE BRAIN 
 
 internal injflammation, asserts its independence of all local 
 action, and ranks itself among the symptoms known to be 
 dependent on a vitiated condition of the circulating fluid ; a 
 position which is strongly supported by the fact that, in gout, 
 an analogous disorder, in which the blood has been shown to 
 be poisoned,^ we meet with a similar affection of the nervous 
 centres, unaccompanied by any evidence of cerebro-spinal 
 inflammation. 
 
 But admitting the altered condition of the blood to be the 
 primary cause of the brain's disturbance, yet as its character 
 is always altered in rheumatism, and head symptoms seldom 
 occur, there must be some further influences at work which 
 determine the occurrence of delirium in certain cases and its 
 total absence in others. By looking carefully to the circum- 
 stances under which cerebral symptoms are most apt to arise 
 in diff"erent disorders, we may glean important information on 
 the subject. It is well known that persons of a nervous ex- 
 citable disposition are more apt to experience ill effects from 
 any interference with their functions, than are others of a more 
 vigorous and less irritable temperament. Moreover, it has 
 been ascertained that nervous susceptibility is most fully dis- 
 played when the constitution has been damaged by habits of 
 intemperance or by long-continued ill health. Not only are 
 persons more prone under such circumstances to suff'er severely 
 from local injuries, but they are apt to exhibit symptoms of 
 irritation from causes which, in persons of a healthy constitu- 
 tion and less excitable habit, would hardly give rise to any 
 disturbance. Thus it is that in habitual drunkards, whose 
 constitutions are shattered, and whose nervous systems have 
 long been unduly exalted or depressed, comparatively small 
 potations on the one hand, or on the other a brief abstinence 
 from accustomed stimulus, or any temporary depressing cause, 
 will seldom fail to induce an attack of delirium tremens. Hence 
 also the frequency of traumatic delirium, and of the delirium 
 which so constantly accompanies erysipelas in persons whose 
 constitutions have been severely taxed. The excess or the 
 1 Vide '• Medico-Chir. Transactions," vol. xxxi, p. 83.
 
 AS COXSEQUENCES OF ACUTE RHEUMATISM. 263 
 
 deficiency of the accustomed stimulus in the case of the drunk- 
 ard ; the sjhock, and the loss of hlood in the case of the wounded 
 man; and the poison of the disease in the last instance, proves 
 sufficient to disturb the relationship subsisting between the 
 blood and the nervous centers. With a brain participating in 
 the general mal-nutrition of the body, — a heart weak, ill 
 nourished, ill supplied with nervous stimulus, and hardly 
 capable of maintaining a due circulation, — and a blood long 
 vitiated or impoverished, it is not difficult to conceive that a 
 slight additional cause of irritation or depression may prove 
 sufficient to disturb the brain's equilibrium, and that an attack 
 of delirium may supervene, whenever, by the presence of some 
 fresh morbific matter, by an increase of the watery part, or a 
 diminution in the colored corpuscles of the blood,^ or, indeed, 
 by any material alteration in the character of the circulating 
 fluid, the nutrition of the nervous centers is still further in- 
 terfered with. Nor is it to be wondered at that, from the same 
 cause, an attack of carditis, or pleuro-pneumonia, should in 
 many cases determine the access of cerebral symptoms. The 
 shock resulting from the occurrence of inflammation in such 
 vital organs as the heart or lungs, must surely so far influence 
 the circulation as to cause the blood to be sent to the brain 
 less forcibly and less regularly than before: indeed, we have 
 proof of such an influence in the weak, irregular, and inter- 
 mittent pulse, by which the invasion of carditis is often accom- 
 panied ; and this, in a person already predisposed by the vitiated 
 condition of the blood, would probably disturb the brain's nutri- 
 tion sufficiently to give rise to symptoms of undue excitement 
 or undue oppression." 
 
 Thus, then, it would appear that, in all cases in which cere- 
 bral disturbance presents itself during the course of acute rheu- 
 
 1 The natural result of hemorrhage or venesection. 
 
 '■* "With the heart patched inside and out with lymph, ulcerated it may be 
 in its very substance and valvular structure, while fevered acid blood is at the 
 same time in circulation through the system, there can be no reason to marvel 
 at the occurrence of 'head symptoms' in rheumatic fever, even though the 
 brain and its investing membranes be not inflamed." (Dr. Wilson, " On the 
 True Character of Acute Rheumatism." "Lancet" for 1844, vol. ii, p. 218.)
 
 264: AFFECTIONS OF THE BRAIN 
 
 matism, the altered condition of the hlood is its primary or 
 proximate cause ; that neither delirium nor coma is necessarily 
 accompanied hy any internal inflammation, whether of the 
 brain, the heart, or the lungs: nevertheless, internal inflam- 
 mation, more especially of the heart and lungs, is very liable 
 to arise as a consequence of the irritation of the vitiated blood ; 
 and "when so arising, is apt to be accompanied by sensorial 
 derangement, for the reason that, under the circumstances of 
 the case, it makes up the sum or amount of derangement which 
 is requisite to disturb the brain's equilibrium. Indeed, so 
 rarely is such disturbance effected in acute rheumatism without 
 its influence, that for all practical purposes delirium may be 
 considered as indicative of some commencing internal compli- 
 cation, and very generally of inflammation of the heart. 
 
 The same holds good in regard to those cases which are 
 attended, not only by disturbance of the intellectual faculties, 
 but by symptoms indicative of spinal irritation. Just as deli- 
 rium may result from the direct action of the rheumatic poison 
 on the brain, so convulsions, and other spasmodic affections, 
 which are sometimes met with in acute rheumatism, may take 
 their origin in spinal irritation caused by the action of the same 
 morbific agent. In the first named cases, dissection after death 
 very generally fails in revealing any trace of mischief within 
 the cranium; and, in the last, the spinal cord and its mem- 
 branes are found equally free from organic lesion. Both classes 
 of cases, however, are usually distinguished by extensive in- 
 flammation of the pericardium or pleurae; and in the one, as in 
 the other, this local inflammation appears to be connected with, 
 if indeed it be not the exciting cause of the disturbance observed 
 in the cerebro-spinal functions. In the former it obviously 
 interferes with the due maintenance of the cerebral circulation, 
 and is thus probably conducive to the setting up of delirium: 
 in the latter it doubtless produces a similar derangement in the 
 spinal system, and so gives rise to convulsive actions. Probably, 
 however, the symptoms in the latter, if not also in the former 
 cases, are more or less connected with the irritation of those 
 branches of the phrenic and pneumogastric nerves which are
 
 AS CONSEQUENCES OF ACUTE RHEUMATISM. 265 
 
 distributed over the inflamed part.s; for it lias been observed 
 that, in the cases most remarkable for choreic or tetanic con- 
 vulsions, and other symptoms of spinal irritation, the inflam- 
 mation has not been confined to the internal surface of the 
 pericardium, but has extended to its external surface and to 
 the diaphragmatic pleura, where branches of the phrenic and 
 pneumogastric nerves are distributed most abundantly.^ 
 
 The description I have given of the circumstances under 
 which cerebro- spinal symptoms are most apt to make their 
 appearance, sufficiently indicates the class of cases in which 
 we may reasonably expect their occurrence. It is not neces- 
 sarily in those persons whose articular inflammations are most 
 numerous and severe, but in those who are pale, weakly, and 
 unhealthy; who have been much reduced by blood-letting, 
 or by excessive and long-continued perspiration ; who are 
 attacked after overlong lactation, or during recovery from 
 serious illness ; or who again, as Dr. Watson has remarked,^ 
 experience a relapse after a long and tedious attack of rheu- 
 matism. It is with rheumatism, just as with gout ; the pleth- 
 oric healthy subject, though undergoing martyrdom from 
 inflammation of his joints, escapes without the slightest disturb- 
 ance of his sensorial functions, while the thin, the sallow, and 
 unhealthy, who have long suff"ered from constitutional derange- 
 ment, whose kidneys and liver are defective in action, whose 
 blood is altogether vitiated, and whose nervous centers cannot 
 
 to ' » 
 
 fail to sympathize largely in the general disturbance, though 
 presenting far less active local symptoms of disease, are aff'ected 
 with delirium, and die comatose or convulsed. 
 
 Thus, then, as head symptoms are invariably connected 
 with great susceptibility of the nervous centers, are usually 
 accompanied by active inflammation of some internal organ, 
 and occur almost always in persons of a weak excitable habit, 
 
 ^ For cases in illustration of these facts, see Dr. R Bright's essay "On 
 Spasmodic Diseases accompanying Affection of the Pericardium," "Medico- 
 Chir. Trans.," vol. xxii ; BouilUiud's " Traite des Maladies du Coeur ;" Dr. Bur- 
 rows, "On Disorders of the Cerebral Circulation," pp. 210-212; and Dr. Hcpe, 
 " On Diseases of the Heart." 
 
 2 " Practice of Physic," ed. 1, vol. ii, p. 283. 
 18
 
 266 AFFECTIONS OF THE BRAIN 
 
 they are always indicative of extreme danger, even when unat- 
 tended by cerebral inflammation. That recovery does take 
 place occasionally, I am satisfied both by personal experience, 
 and by the testimony of others who have watched and noted 
 cases in point, but, when the delirium is violent, and of long 
 continuance, the result cannot be otherwise than doubtful. 
 Whether recovery does ever occur when the delirium is de- 
 pendent upon cerebral inflammation, it is impossible from ex- 
 perience to decide, inasmuch as convalescence itself forms a bar 
 against our only source of positive information. But if, in any 
 case accompanied by symptoms of active cerebral disturbance, 
 no cardiac or pulmonary disease should be detected, it would be 
 right, cseteris paribus^ to speak more decidedly as to an unfa- 
 vorable issue, than if the stethoscope had revealed mischief 
 within tlie chest. 
 
 The following instructive case, which fell under my observ- 
 ation in St. George's Hospital, affords a good example of the 
 class of cases in which, and of the circumstances under which, 
 rheumatic delirium is most liable to occur, as also of the train 
 of symptoms by which it is accompanied. 
 
 Harriet Keating, a poor, thin, over-worked girl, set. 19,^ 
 was admitted into the Holland Ward on the 9th of October, 
 1850, under the care of my colleague. Dr. Wilson. She had 
 been seized with acute rheumatism in the year 1848, and had 
 undergone four similar attacks ^ince that date. Her present 
 attack, which had been preceded for three Aveeks by languor, 
 chilliness, wandering pains, and general uneasiness, commenced 
 on the 6th instant with redness and swelling of the knees. On 
 the 8th, the day prior to her admission, she had been bled to 
 the extent of a pint with slight temporary relief, but when she 
 was admitted, the knees and ankles were red, swollen, and 
 extremely painful, her countenance was anxious, and she had 
 a^weak pulse of 120. On the following day she was decidedly 
 worse ; her countenance was more anximis, she was com- 
 plaining of excessive pain in the limbs, and had experi- 
 enced several fits of shivering. On the 11th, after a restless 
 and sleepless night, during which the inflammation shifted to 
 1 .She was a servant of all work.
 
 AS CONSEQUENCES OF ACUTE RHEUMATISM. 267 
 
 the right wrist and elbow, she presented symptoms even more 
 alarming than on the previous day. Her face was flushed, 
 and, though no distinct murmur could be heard accompanying 
 the heart's sounds, the pulse had risen to 130, and Avas sharp 
 and somewhat irregular. The morning of the 12th found the 
 inflammation again shifted to the inferior extremities, her face 
 more flushed, the pulse quicker, sharper, and more irregular, 
 and the heart's sounds accompanied, or rather masked by a 
 loud to-and-fro sound of friction. The treatment up to this 
 time had consisted of lemon-juice, with occasional doses of 
 opium or morphia, but twelve ounces of blood were now taken 
 from the arm, and she was put upon calomel and opium, while 
 leeches and mustard poultices were applied to the chest. By 
 the 20th she was greatly relieved ; she had passed a tolerably 
 good night ; the dullness on percussion in the prsecordial re- 
 gion had greatly decreased, the heart's sounds were clearer 
 and louder, and no sound of friction could any longer be heard 
 except quite at the base of the heart. But on the 21st there 
 was some return of catching pain in the left mammary region, 
 and the stethoscope revealed incipient endocardial inflammation. 
 Eight leeches were, therefore, again applied to the region of 
 the heart, while the mercury was continued as before. Never- 
 theless, an intense systolic murmur, audible both at the apex 
 and the base of the heart, was shortly developed, the pulse 
 increased in frequency, her face again became flushed and the 
 countenance extremely anxious, so that, on the twenty-fifth, it 
 was judged expedient to take eight ounces more blood from the 
 arm. Still the mischief continued, and, as by the 27th her 
 mouth had become slightly aff"ected by the mercury, tlie pills- 
 were omitted, and a third of a grain of tartar emetic was given 
 every four hours, and a blister applied to the chest. After 
 two more nights of extreme restlessness, a new train of symp- 
 toms presented themselves. Her pupils became exceedingly 
 dilated, the eyes rolled wildly, and she was greatly excited in 
 her manner. As the pulse was quick and weak, and jerking, 
 the antimony was omitted, and half a grain of the acetate of 
 morphia was given twice a day. On the 30th it was repeated 
 every six hours. In the evening of that day, furious delirium.
 
 268 AFFECTIONS OF THE BKAIN 
 
 supervened, and was accompanied on the following day by 
 violent tetanic spasms, Avhich gave rise, amonrr other actions, 
 to firm clinching of the fingers. In spite of morphia and 
 digitalis, which were now given in full doses every four hours, 
 and of calomel, which was again administered freely with the 
 view of arresting the progress of the endocarditis, while ice 
 was applied to the head, the delirium continued incessant up 
 to the 6th of November, when she seemed thoroughly ex- 
 hausted and lay motionless on her back, with the pupils 
 exceedingly dilated, her mouth open, the tongue half pro- 
 truded, dry, and brown, and the pulse rapid, feeble, irregular, 
 and intermittent. Indeed, she appeared tobe sinking; but 
 she was made to swallow some strong beef tea, and was given 
 half a drachm of Hoffmann's ether, and a quarter of a grain 
 of morphia. Under the influence of this medicine, which Avas 
 repeated every three hours, symptoms of improvement soon 
 began to manifest themselves. The pulse rallied, and again 
 she began to talk and rave. By the 10th, however, the deli- 
 rium had greatly subsided, and she had obtained a few hours' 
 sleep. By the assistance of bark, which was now adminis- 
 tered as well as morphia, the improvement was fully sus- 
 tained. On the I3th, wine was given in addition to the medi- 
 cine, and, again, a marked improvement was observed. She 
 became more tranquil and less flushed, the pulse became 
 gradually steadier and fuller, and the heart" s sounds clearer. 
 By the 15th, a slight systolic valvular murmur alone remained; 
 the pulse had fallen to 100, and was soft and regular, the 
 tongue was moist and almost clean, and her appetite tolerably 
 good. But her mental faculties had not yet regained their 
 proper balance. She would protrude her tongue when bid to 
 do so, but she talked incessantly and incoherently, and often- 
 times santT snatches of various sonsis strung together in an 
 unconnected manner. In this half-maniacal, half-idiotic state, 
 in which she was at times so violent as to require a strait- 
 waistcoat, and at others was only troublesome and mischiev- 
 ous, she remained until the 24th, when, after a good night's 
 rest, fhe became, for the first time, decidedly more tranquil. . 
 
 By the 27th, under the influence of a nourishing diet, and the ■I
 
 AS CONSEQUENCES OF ACUTE RHEUMATISM. 269 
 
 continued use of stimulants and sedatives, she had so far im- 
 proved that, although still excitable and strange in her man- 
 ner, she was allowed to dress and get up during the day, and 
 from this time her progress toward recovery was steady. On 
 the 14th of December she left the Hospital to go for a short 
 time to the Sanatorium at Carshalton. A slight i^ystolic mur- 
 mur, most audible toAvard the apex of the heart, alone re- 
 mained to tell the tale of her fearful cardiac seizure ; she no 
 longer suffered any pain or uneasiness in the region of the 
 heart, and, although weak, she was daily regaining strength. 
 
 How beautifully does this case illustrate and explain *the 
 nature of the delirium in many of these instances ! And how 
 suggestive is it of the appropriate treatment ! A poor, thin, 
 ill-conditioned girl, exhausted by work, and weakened by the 
 occurrence of four attacks of rheumatic fever, within the short 
 space of two years, is bled to the extent of a pint for the relief 
 of symptoms occasioned by a poison engendered in the system 
 by faulty assimilation. What so likely to augment the mis- 
 chief, to impoverish her blood, already poor and deficient in 
 colored corpuscles, and to exalt the excitability of the heart, 
 the brain, and the system generally ! As might have been 
 expected, the heart, damaged, as it were, and rendered irrita- 
 ble by the Avithdrawal of its natural and necessary stimulus, 
 became unusually susceptible of morbid influences, and suc- 
 cumbed under the irritation of the rheumatic poison. Peri- 
 carditis commenced, and, for the relief of that inflammation, it 
 was judged expedient to abstract more blood, and employ other 
 active and depressing remedies. Their influence on tlio local 
 action was soon beneficially exerted, and the inflammation was 
 checked. But ere long it broke out in a new quarter. No 
 sooner was the pericardial inflammation subdued, than endo- 
 carditis commenced with extreme violence ; with such severity, 
 indeed, that it was again deemed necessary to have recourse to 
 leeches and general blood-letting, and to recommence the ad- 
 ministration of lowering medicines. Again the beneficial in- 
 fluence of the remedies over the course of the cardiac mischief 
 was clearly manifested, but the brain began to sympathize Avith 
 the general distress ; it had sustained its functions in spite of
 
 270 AFFECTIONS OF THE BRAIN 
 
 the attack of pericarditis, and for eight days after the invasion 
 of endocarditis, but it gave way at length under the extreme 
 disturbance which its nutrition had undergone. The blood 
 which supplied it had long been vitiated and impoverished; 
 the heart which circulated that blood had been rendered inca- 
 pable of performing its work properly by an attack of inflamma- 
 tion, both on its external and internal surface; a large quantity 
 of tl e blood, which, vitiated as it was, had been the only source 
 of nourishment to the nervous centers, had been withdrawn with 
 the view of arresting the rheumatism and checking the prog- 
 res^ of the cardiac inflammation, and medicines of a most de- 
 pressing character had been freely administered for the same 
 purpose. No Avonder that, under such a combination of cir-" 
 cumstances, the cerebral structures should have exhibited some 
 token of deranged function. At first, slight wandering only 
 was observed at night, together with wildness of manner and 
 expression, but this was speedily followed by active delirium, 
 and by more or less convulsive action. Morphia and digitalis 
 administered freely, and the constant application of ice to the 
 head, failed utterly in afi'ording relief to these symptoms, as did 
 also calomel in full and repeated doses. After a time, however, 
 it became obvious that the symptoms were referable to "excite- 
 ment without power,"^ and morphia was therefore resorted to 
 again in combination with sulphuric ether. The stimulant in 
 combination with the sedative at once effected what the latter, 
 by itself, had proved incapable of doing. The brain had long 
 been subjected to depressing influences, and required its failing 
 energies to be roused, as well as its abnormal irritability sub- 
 dued and tranquilized, and as day by day this was more fully 
 eff"ected by means of nourishment, stimulants, and sedatives, it 
 became apparent how great was the benefit derived. The 
 brain gradually reassumcd more and more of its healthy func- 
 tions in proportion as the pulse betokened a return of power. 
 Without entering largely into the detail of cases which in 
 
 1 This expression, which serves admirably to explain the real nature of the 
 symptoms, was first applied, I believe, by Dr. Gooch, to a peculiar form of 
 puerperal mania.
 
 AS CONSEQUENCES OF ACUTE RHEUMATISM. 271 
 
 their repetition can serve no practical end, I will briefly narrate 
 such particulars of one or two as may tend to throw light upon 
 the subject of rheumatic delirium, and to illustrate some of the 
 facts already mentioned. And first, in regard to the rarest of 
 all forms of head afifection occurring in connection Avith rheu- 
 matism, that, namely, in which the brain or its membranes are 
 inflamed. 
 
 A man who had long suff'ered from rheumatism was admitted 
 into St. George's Hospital, under the care of Dr. Seymour, 
 with his joints inflamed and swollen. One day his knees, which 
 had been greatly swollen, became very much smaller and flaccid, 
 and, coincidently with the subsidence of the swelling, he com- 
 plained of pain in the head, became paralyzed on one side, and 
 expired in the course of thirty-six hours. On opening his body 
 a large quantity of greenish-looking purulent matter was found 
 smeared over the greater part of the surface of the left hemis- 
 phere, and there was considerable effusion into the ventricles.' 
 So, also, in a case of Dr. Watson's. A female patient, who had 
 rheumatic fever and subsequent cerebral symptoms, died in the 
 Middlesex Hospital; and upon examination of the brain, un- 
 equivocal pus was found smeared over the hemispheres.^ So, 
 again, in a case reported by Dr. Fife, of Newcastle-upon-Tyne." 
 The patient, a man 36 years of age, after suffering for some 
 days from acute rheumatism, was seized with delirium and 
 unequivocal symptoms of cerebral inflammation. Life contin- 
 ued for five days longer, and throughout that period there was 
 either muttering delirium or a state of perfect coma. On the 
 fifth day, at noon, he died ; and dissection showed the mem- 
 branes of the brain covered with lymph and pus, the vascu- 
 larity of the brain enormously increased, and the lateral 
 ventricles distended with serum — sufficient indications of true 
 inflammation. 
 
 In these three cases, and indeed in all similar instances of 
 which I can find records, the cerebral inflammation does not 
 
 1 Dr. Seymour's Clinical Lecture. ■■ Medical Gazette," vol. xix. 
 
 2 Quoted in Dr. Todd's Lutnleian Lectures for 1850. 
 * " Medical Gazette," vol. xxix, p. lo:i.
 
 272 AFFECTIONS OF THE BRAIN 
 
 appear to have been a simple extension of the disease, but to 
 have been excited by the concentration of the rheumatic virus 
 upon the brain in consequence of the sudden subsidence of 
 articular inflammation. 
 
 Inflammation of the brain, however, as ah'eady stated, is a 
 rare accompaniment of acute rheumatism ; the head sj'raptoms 
 observed in the course of that disease being more commonly 
 symptomatic of pericarditis, endocarditis, or acute pleurisy. 
 Two of the cases, (Nos. 1 and 3.) the outlines of which are 
 given in a former chapter,^ afford an illustration of this import- 
 ant fact, as do also many cases which others have put on record. 
 Thus, one of the children of Christ's Hospital, who was suff'er- 
 ing from acute rheumatism, was attacked, on the third day of 
 his illness, with delirium and convulsions. The attack was 
 sudden, with great heat of skin and frequency of pulse, and, 
 in the opinion of all who saw the case, it Avas an instance of 
 the severest inflammation of the brain. The boy pointed to 
 his forehead as the seat of pain. On the fourth day he sank 
 into a state of insensibility and died, and upon dissection, not 
 a vestige of disease was found within the cranium, but the 
 heart was exclusively the seat of mischief, and no other part of 
 the body exhibited the slightest morbid appearance. The dis- 
 ease of the heart was not confined to its investing membrane. 
 It was the most intense inflammation pervading the pericardium 
 and the muscular structure." So, again, Dr. Richard Bright 
 reports of a young man whom he attended in the year 1836. 
 He had been suff'ering from acute rheumatism six days, when 
 spasmodic symptoms appeared, increased rapidly in severity, 
 and were shortly accompanied by delirium. This ultimately 
 became so violent that it was found necessary to put the unfor- 
 tunate sufferer under restraint. He died at the expiration of 
 three weeks, and on dissection the brain was found perfectly 
 healthy, and the pericardium and endocardium presented une- 
 
 1 Ciip. YII. pp. 100. 191. 
 
 2 The particulars of this case are detailed by Mr. Stanley, in vol. vii of the 
 ■' Medico-Chir. Trans."
 
 AS CONSEQUENCES OF ACUTE RHEUMATISM. 273 
 
 quivocal signs of recent active inflammation.^ Dr. Watson has 
 placed several cases on record, in one of which the endocardium 
 alone was the seat of inflammation.^ In another, a girl, 17 
 years of age, after suffering from acute rheumatism between 
 two and three weeks, became so furiously maniacal that it was 
 found necessary to confine her by means of a strait-waistcoat. 
 She continued in the same state until she died ; yet the brain 
 was found perfectly healthy, and the only discoverable organic 
 lesion was in the pericardium, which was universally coated, on 
 its internal surface, by a thick layer of recent lymph. ^ Dr. 
 George Burrows and Dr. Todd have also met with cases in 
 point. The former tells us of a shop-boy, who, after seven days' 
 illness, expired in a state of restlessness and delirium, and 
 upon examination of the body the pericardium was found cov- 
 ered with a net-work of recent lymph, while " upon the anterior 
 surface of the left ventricle of the heart, there was a white spot 
 about a quarter of an inch in diameter, which appeared to be 
 formed by concrete pus."^ The latter reports that a young 
 woman, after suffering for some days from rheumatic fever, was 
 seized with delirium, and in a few hours afterward had a convul- 
 sive fit, succeeded by coma and death ; yet the closest examination 
 of the parts after death, while it exposed extensive inflammation 
 of the pericardium, could not detect a trace of inflammation of 
 the brain, which, together with its membranes, were unusally 
 pale.'* 
 
 The third class of cases, or those in which rheumatic delirium 
 is unaccompanied by internal local inflammation, are of much 
 rarer occurrence, inasmuch as when the constitutional derange- 
 ment is so great as to occasion disturbance of the nervous cen- 
 ters, the rheumatic poison is present in large quantity, and 
 usually gives rise to cardiac inflammation. But, though com- 
 paratively rare, they do sometimes occur. Dr. Todd has made 
 mention of some, and I have myself seen eight, in which slight 
 
 1 " Medico-Chir. Trans.," toI. xxii. 
 
 2 " Medical Gazette," vol. xvi, p. 93. 
 
 3 " Practice of Physic," ed. 1, vol. ii, p. 276. 
 
 * " On Disorders of the Cerebral Circulation," p. 188. 
 5 Lumleian Lectures, published in the " Lancet" for 1852.
 
 274 AFFECTIONS OF THE BRAIX 
 
 wandering or delirium lias arisen, and has continued for several 
 hours, although the stethoscope has failed in detecting the 
 slightest mischief within the chest, and the general symptoms 
 have been inconsistent with the occurrence of inflammatory 
 action within the cranium. One instance has lately occurred 
 to me in which a fatal result ensued. The patient was a gen- 
 tleman, 39 years of age, who had been weakly and out of 
 health for many months prior to the commencement of the 
 attack. He was seized with S3'mptoms of acute rheumatism on 
 the 15th of February, 1856, and I was called in consultation 
 by my friend Mr, Kesteven, on the 22d instant, the eighth 
 day of the attack. The patient was low and irritable, and his 
 complaint of pain was out of all proportion to the apparent 
 severity of the articular inflammation ; but in other respects 
 there was nothing worth noting until the 26th instant, when, 
 after forty-eight hours of almost entire sleeplessness, he became 
 more than ever restless, tremulous, and excited. These symp- 
 toms passed off in the morning of the 27th, but, in spite of 
 opium, reappeared with increased violence toward evening. 
 On the 28th, he was sensible when spoken to, but restless and 
 excited to the highest degree, talking incessantly, moving rap- 
 idly about in bed, and using his hands to pull himself up, in 
 utter disregard of the swollen and painful condition of the left 
 wrist-joint. His head was not hot, and he declared that it was 
 and ever had been perfectly free from pain. Occasionally he 
 could see only half of any object at which he was looking ; his 
 pupils were much dilated, but acted under the stimulus of 
 strong light ; the pulse was rapid, feeble, and fluttering, the 
 tongue dry, but not much coated. His heart, which had been 
 examined daily, and twice a day, still remained perfectly free 
 from mischief. Diffusible stimulants and sedatives were given, 
 but without effect. With the approach of evening, the symp- 
 toms of excitement again increased, he could with difficulty be 
 kept in bed, and he talked incessantly and in a most incoherent 
 manner. About 12 p.m. the restlessness subsided, he became 
 calm and collected, said he felt he should die, called for his 
 wife and children, and gradually expired about half-past one
 
 AS CONSEQUENCES OF ACUTE RHEUMATISM. 275 
 
 in the morning of the 2Uth. My friend Mr. Pyle, of Oxford 
 Terrace, Hyde Park, has favored me with the particulars of 
 another case. A gentleman, while laboring under symptoms 
 of acute articular rheumatism, became affected by tetanic 
 spasms, opisthotonos, and convulsions. Delirium of a violent 
 character supervened, and the unfortunate sufferer could with 
 difficulty be kept in bed. Nevertheless, Dr. Latham and Mr. 
 Pyle, who both examined him daily by the stethoscope, failed 
 in detecting anything abnormal in the condition of the heart, 
 the lungs, or the pleur?e, and were both persuaded, from the 
 character of the accompanying symptoms, that no inflammation 
 had been set up in the brain or spinal cord. In all the cases 
 alluded to, the patient's recovery, or the absence of post- 
 mortem investigation, has rendered it impossible to obtain more 
 than presumptive proof of the non-existence of internal inflam- 
 mation ; but cases are occasionally met with, in which the 
 effects of cerebro-spinal irritation are manifested by furious 
 delirium and violent spasmodic action, terminating only with 
 the patient's life, and in which, therefore, it is possible, by a 
 post-mortem examination, to obtain positive evidence as to the 
 absence of carditis, and of every other form of internal inflam- 
 mation. Such a case occurred at St. George's Hospital, in the 
 year 1850. It has been already referred to in a previous chap- 
 ter ;^ but the inferences deducible from it are of such import- 
 ance, that I do not hesitate to give it in detail. 
 
 Ann Amess, aet. 21, servant of all work, who had suffered 
 from slight rheumatism a year before, was seized, on the 17th 
 of January, with wandering pains in the limbs, accompanied 
 by redness and swelling of the joints, for which she put herself 
 under medical treatment on the 19th. On the 24th, she was 
 admitted into Pepy's Ward, under the care of my colleague, 
 Dr. Bence Jones. There were redness and sAvelling in some of 
 her joints, with excessive pain in all, and she was complaining 
 of a catching pain in the cardiac region. Her face was 
 exceedingly flushed, and her pulse quick, but by no means 
 sharp. A soft systolic murmur, which increased in intensity 
 1 Cap. VII, p. 201.
 
 276 AFFECTIONS OF THE BRAIN 
 
 in tlie course of three days, was audible over the base of the 
 heart, but this, from its position and the direction in which it 
 was heard, was regarded as having an anremic origin. In short, 
 no evidence coukl be obtained of mischief within the chest. 
 The perspiration was most profuse, and on the 27th, a crop of 
 miliary vesicles appeared upon the chest. No other symptom 
 worthy of note presented itself, until the evening of the 31st, 
 when the nurse observed that the patient was restless, and 
 rather flighty and delirious. These symptoms subsided in the 
 morning, but only to reappear on the following evening with 
 increased violence and obstinacy. They did not now subside 
 toward morning : the dawn of day showed her restless, trem- 
 ulous, and excited, and, with the approach of evening, she 
 became still more excited and delirious. Morphia had been 
 given in vain : and laudanum, in full doses, was now resorted 
 to, with the view of tranquilizing the nervous centers : but the 
 head symptoms rapidly increased in severity ; she became vio- 
 lently delirious, so that she had to be held in bed ; she then 
 lapsed into a state of coma, and expired on the morning of the 
 3d of February. When coma supervened, Mr. llammerton, 
 the resident medical officer, bled her to six ounces, and the 
 blood was neither buffed nor cupped. 
 
 After death, dissection showed the brain and its membranes 
 rather drier than usual, but without any other remarkable 
 appearance ; the lungs congested, but otherwise healthy, and 
 the pleurae adherent here and there to the parietes of the chest 
 by old and firm adhesions, but exhibiting no trace of recent 
 inflammation. The pericardium contained about two ounces of 
 serum ; the heart and its valves loere perfectly healthy,^ its right 
 cavities contained fibrinous coagula. The peritoneal cavity 
 contained a small quantity of turbid serum. The liver and 
 pancreas Avere healthy ; the spleen soft and flabby ; the kidneys 
 
 1 Such at least is the record of the post-mortem appearance preserved by our 
 Curator, in the Museum of the Hospital, and it serves to show the extent of 
 " the very slightest roughness''^ which, in the record of the same case, in the 
 " Transactions of the Pathological Society," is mentioned as having been 
 observed at one spot on the surface of one of the auricles. There was not the 
 slightest injection of the pericardial membrane.
 
 AS CONSEQUENCES OF ACUTE RHEUMATISM. 277 
 
 slightly congested, especially the right, but perfectly healthy 
 in appearance. The synovial membrane of both knee-joints 
 ■was highly vascular, and their cavities contained a quantity 
 of turbid, yellow serum, in which masses of lymph were 
 floating. 
 
 Here, then, is a remarkable case in point. The patient was 
 a servant of all work, who, as I am informed by my colleague, 
 Mr. Keate, who sent her into the hospital, had been sitting up 
 at night for some time, engaged in nursing an invalid. He told 
 me, when she was first admitted, that she was much exhausted 
 by her labors; and the loud anemic murmur which was heard 
 throughout the attack, and the crop of sudamina which very 
 shortly appeared, attested the correctness m)^ his judgment. 
 Then came the delirium, indicative of the irritability consequent 
 on that exhaustion ; and in direct corroboration of the evidence 
 afl"orded by the symptoms, the blood drawn from the arm was 
 neither buffed nor cupped. After death the chain of evidence 
 was completed. The brain and its meninges, the lungs and 
 their envelopes, the heart and its membranes, both external 
 and internal, were closely and carefully examined, but no trace 
 of inflammation could be found, and the ftict became apparent 
 that the symptoms observed during life were due to the morbid 
 blood acting upon nervous centers, rendered more than usually 
 susceptible of irritation by the exhaustion to which the patient 
 had been subjected. The delirium was obviously referable 
 neither to congestion nor inflammation, but to excitement with- 
 out power. 
 
 In illustration of the severity which spinal symptoms may 
 assume in connection with acute rheumatism, the following 
 very remarkable case may be cited : A boy, 16 years of age, 
 was admitted under the care of M. Bouillaud, suffering from 
 severe cramps and tetanic spasms, affecting almost every part 
 of his frame. It appeared that he had been attacked with 
 acute rheumatism about a fortnight previous to his admission ; 
 convulsive contraction of the fingers, after a time, supervened ; 
 and subsequently, tetanic spasms commenced in various parts 
 of the body.
 
 278 AFFECTIONS OF THE BRAIN 
 
 When first seen by M. Bouillaud, liis countenance was most 
 anxious, his eyes were fixed, and the pupils dilated. His in- 
 tellect was unobscured, but the voice was rendered trembling 
 by the constant sobs called forth by the severity of the cramps 
 in his limbs. No part of his body was free from pain. The 
 mouth could hardly be opened, so firmly and spasmodically was 
 it closed ; his fingers, arms and forearms, toes and feet, were 
 violently contracted, and the muscles of the abdomen, no less 
 than those of the extremities, were hard as stone during the 
 spasms. Added to all this suffering was a constant sense of 
 sufi'ocation. In spite of general and local blood-letting, toge- 
 ther with warm baths and the internal administration of opium, 
 the attacks of spasm recurred continually; symptoms of trismus 
 became more urgent and distressing; the least attempt to swal- 
 low very greatly aggravated his suffering ; and he died, ex- 
 hausted, on the tenth day from the first appearance of spasms 
 in the fingers. 
 
 The spasms had been regarded as symptomatic of inflamma- 
 tion of the spinal cord, but dissection revealed an injected 
 condition of the pericardium, and within its cavity about two 
 ounces of pure creamy greenish pus, while in the brain and its 
 meninges a slight congestion only was observed, and in the 
 spinal cord and its membranes there was no unusual appear- 
 ance beyond a small circumscribed spot of softening at the 
 superior enlargement of the cord.^ 
 
 Death, however, is not a necessary consequence of cerebro- 
 spinal irritation, and, therefore, however alarming the symp- 
 toms, our prognosis should be extremely guarded. I have 
 already narrated the particulars of one case" which fell under 
 m}'^ own observation in which recovery took place under cir- 
 cumstances which almost precluded the possibility of such an 
 event ; and an equally favorable issue occurred in another case 
 which came under the care of Dr. Edward Dewees, at the 
 Coventry and Warwickshire Hospital. A young woman, set. 
 19, was attacked on the 12th of January with feverishness, 
 accompanied, on the following day, by redness and swelling of 
 
 1 Bouillaud's " Traite des Maladies du Coeur," torn, i, p. 333, 
 
 2 Page 206, of this Treatise.
 
 AS CONSEQUENCES OF ACUTE RHEUMATISM. 279 
 
 the various joints, and by other characteristic symptoms of 
 acute rheumatism. She manifested no untoward symptom 
 until tlie 17th, when her heart gave tokens of commencing 
 inflammation, and she became restless, talkative, and flighty. 
 On the 18th an exocardial friction-sound was heard, as was 
 also a loud systolic murmur ; and altogether, she was much 
 worse. She had not slept, and "she was so violent that it 
 required two or three persons to keep her in bed." " The 
 right arm was in a state of constant jactitation, so that it was 
 never still for an instant ; the right leg was similarly aff'ected, 
 but to a less extent ; at times, however, this state became ag- 
 gravated into one of general convulsions of a tetanic character." 
 She continued in the same maniacal condition for nine days, 
 during which time the convulsions continued incessantly, and 
 she had no sleep. " On the 23d she suddenly jumped up, and 
 fell out of bed, her forehead coming in contact with the floor." 
 On this she became comatose, but the coma was relieved by the 
 application of a few leeches to the head. " The treatment 
 throughout consisted of bleeding, general and local, repeated 
 blistering, and mercurialization ;" and as soon as the system 
 was brought fully under the influence of mercury, the severe 
 symptoms were materially alleviated. On the l3th of Febru- 
 ary she was convalescent, the systolic murmur alone remaining,^ 
 Thus, then, where delirium, convulsions and coma occur in 
 the course of acute rheumatism, the first point to be ascer- 
 tained is their connection or non-connection with any internal 
 local inflammation. If we are unable to discover any signs of 
 cardiac or pulmonary inflammation, and from the absence of 
 symptoms of cerebral or spinal inflammation are led to regard 
 the disturbance of the nervous centers as functional only, then, 
 as in delirium tremens, or erysipelas, the invasion of head 
 symptoms should be a signal to support and tranquilize our 
 patient by the administration of nourishment, stimulants, and 
 opiates. In no case is opium, in combination with diff"usible 
 stimulants, of greater service than in this atonic form of deli- 
 rium ; and in none is venesection more prejudicial. If, on the 
 1 '• Medical Gazette," new series, vol. x, p. 457.
 
 280 AFFECTIONS OF THE BRAIN 
 
 Other hand, we detect active cardiac or puhiionary mischief, or 
 from the presence of symptoms of inflammation of the brain, 
 such as excessive heat of head, injection of the eye, intoler- 
 ance of light, and vomiting occurring coincidently with hard- 
 ness of the pulse, and other symptoms of acute inflammation, 
 we are led to suspect the existence of cerebral inflammation, 
 then are we justified in having recourse to such antiphlogistic' 
 or other remedial measures, as appear called for by the symp- 
 toms in each particular instance. In such cases our efi"orts 
 should be directed to the speedy subjugation of those actions 
 going on within either the chest or the cranium, which expe- 
 rience has proved to be intimately connected with the occur- 
 rence of cerebro-spinal symptoms, and on the cessation of 
 which it teaches us to believe we may reasonably expect their 
 subsidence. But as it is notorious that venesection and other 
 depletory measures have a tendency to reduce the proportion 
 of red corpuscles in the blood,' and to produce a condition 
 
 ' See Note. p. 93. of this Treatise. MM. Becquere land Rodier, after ana- 
 lyzing their experiments, as to the effect produced by venesection on the 
 blood, sum up by stating, " in short, the efl'ect of venesection is to cause a 
 great diminution of the corpuscles." (Simon's " Chemistry," vol. i, p. 250.) 
 In confirmation of this fact, I may cite some experiments detailed in Dr. 
 Todd's Lumleian Lectures for 1850 : " A large and well-nourished dog, appar- 
 ently in perfect health, was fed daily on two pounds of meat and a quart of 
 milk. He was bled on four successive days, to the extent of six ounces each 
 day. and the blood carefully analyzed. The blood drawn on the first bleed- 
 ing, on the 6th of April, contained in 1000 parts — 
 
 14285 Corpuscles, 
 
 2-45 Fibrin, 
 783-79 Water. 
 That on the second bleeding, on the 7th of April, exhibited a diminution of 
 the corpuscles, and an increase of the water to — 
 
 11.3-54 Corpuscles, 
 
 4-72 Fibrin, 
 810-89 Water. 
 On the third bleeding, on the 8th of April, the corpuscles had again dimin- 
 ished, and the water increased to— 
 
 110-58 Corpuscles, 
 
 4-34 Fibrin, 
 815-18 Water. 
 And on the fourth bleeding, there were found— 
 106*96 Corpuscles, 
 
 3-99 Fibrin, 
 813-04 Water.
 
 AS CONSEQUENCES OF ACUTE RHEUMATISM. 281 
 
 favorable to the development of delirium and convulsions, we 
 should be exceedingly cautious in having recourse to their 
 employmont, lest by still further impoverishing the blood, and 
 impairing the powers of the constitution, we seriously endan- 
 ger our patient's recovery. In cases marked by evident symp- 
 toms of cerebro-spinal inflaynmation, it may be necessary to 
 have recourse to blood-letting ; but if in ordinary cases of 
 rheumatic carditis the expediency of venesection is question- 
 able, much more so is it in those where the nervous centers 
 are irritable, and are suffering from the effects of malnutri- 
 tion, arising from an altered condition and an irregular sup- 
 ply of blood. Even local depletion, though sometimes expe- 
 dient in such cases for the relief of active local inflammation, 
 should be seldom practiced to any great extent. We should 
 rather endeavor to support our patient, while aiming at the 
 relief of the more urgent symptoms, by means of blisters, mer- 
 curials, diuretics, and opium. We should economize strength 
 by administering opium in doses sufficient to relieve the pain 
 and tranquilize the excited nervous centers, and at the same 
 time support the fading powers of the system by means of 
 a nourishing and stimulating diet. Thus Ave may check the 
 tendency to death, and give our remedies time to play their 
 part. By degrees as the cardiac inflammation is subdued, the 
 fluid Jeffused into the pericardial sac is reabsorbed, and the 
 heart gradually acquires greater freedom of action. Coinci- 
 dently with this improvement in the center of circulation a 
 corresponding improvement is effected in the blood by the 
 gradual elimination of the rheumatic poison, and thus the irri- 
 tability of the nervous centers is lessened, and the symptoms 
 gradually subside. One exception only exists to the full, 
 though cautious exhibition of opium. I refer to those in- 
 stances in which there is a tendency to the supervention of 
 coma. In such cases opium is not only useless, it is decidedly 
 prejudicial to the safety of the patient, who requires a more 
 than usual amount of support and stimulus. 
 
 Thus much then for those affections of the nervous system, 
 which, from time to time, arise in the course of ac ute rheu- 
 19
 
 282 INFLAMMATION OF THE LUNGS AND PLEURA 
 
 matism, and cannot but prove a source of perplexity and 
 anxiety. 
 
 Another complication which adds greatly to the danger 
 attendant upon this disease, is inflammation of the lungs and 
 their membranous coverings; inflammation attacking some- 
 times one, sometimes another part of the pulmonary structure, 
 sometimes invading all parts simultaneously, producing dysp- ' 
 noea, suflfocation and death. " Such forms of pulmonary in- 
 flammation are portentious ingredients in the clinical history 
 of acute rheumatism, and give a fearful interest to it,"' and 
 they are the more formidable from the fact that they gen- 
 erally coexist with inflammation of the investing membrane of 
 the heart. In some instances, the pulmonary inflammation 
 may be excited by simple contiguity of the affected structures, 
 but more generally, whether the attack be bronchitis or pneu- 
 monia, or whether it assumes the form of pleurisy, it is due to 
 the same cause of irritation, the same morbific agent which 
 excites the articular and cardiac aff"ections.^ Hence its ap- 
 pearance is fraught with unusual danger. For, as the pri- 
 mary cause of inflammation is difi"used throughout the blood, 
 and consequently comes in contact with every part of the pul- 
 monary tissue, inflammatory action is no sooner excited than 
 it spreads with fearful and life-destroying rapidity, and as its 
 cause is persistent, so its course is obstinate and little under 
 the control of medicine. "Whichever disease occurred," says 
 Dr. Latham, " it always put on a serious character, either 
 from the mere magnitude and extent, or from the force of 
 morbid action, or from the stage at which it ultimately ar- 
 rived. In the four instances of bronchitis, the affection was 
 no mere catarrh, but an inflammation largely diff'used through 
 both lungs, producing deep oppression and dyspnoea. Of the 
 two pleurisies, one was single and the other double. The single 
 pleurisy produced a large eff'usion into one side. The double 
 pleurisy produced a double hydrothorax. Of the 18 instances 
 of pneumonia, in 9 the disease was of one lung, and in 9 it 
 was of both." 
 
 1 Latham's "Clinical Medicine." vol. i. p. 162. 
 
 2 See note at p. 151 of this Treatise.
 
 AS A CONSEQUENCE OF ACUTE RHEUMATISM. 283 
 
 My experience at St. George's Hospital tallies very closely 
 with that of Dr. Latham at St. Bartholomew's. He has re- 
 ported some form of pulmonary affection in 24 out of 18(3 
 cases of acute rheumatism, or, in other words, in 1 out of 
 every 5*6 cases; and of the 246 cases of acute rheumatism 
 which were admitted during the time I was medical Registrar, 
 41, or exactly 1 in every 6, were complicated by some form 
 of pulmonary inflammation. Among the cases which were 
 uncomplicated by recent cardiac affection, 7 instances only of 
 pulmonary inflammation were observed; among those which 
 were complicated by recent endocardial affection alone, 8 ex- 
 amples were noted: among those accompanied by pericarditis 
 alone, 7 : and among those accompanied by endo-pericarditis, 
 19 occurred. In other words, some pulmonary affection of an 
 inflammatory nature was observed — 
 
 In 7 out of 127' or in 1 out of every 18-1 cases uncomplicated bj- recent 
 
 cardiac mischief. 
 
 ■' 8 " 801 u I 11 ^0-0 cases complicated by recent 
 
 endocardial affection alone. 
 
 " 7 " 12 " 1 " 1-7 cases complicated by exocardial 
 
 inflammation alone. 
 
 " 19 " 27 " 1 " 1-4 cases complicated by endo-peri- 
 
 carditis. 
 
 In the first class of cases, the affection was in six instances 
 bronchitis, in one pneumonia. 
 
 In the second, it was twice bronchitis, four times pneumonia, 
 and twice pleuro-pneumonia. 
 
 In the third, it was partly bronchitis, partly pneumonia in 
 four instances, pleurisy in one instance, and partly pneumonia, 
 partly pleurisy in the remaining two. 
 
 In the fourth, it was bronchitis in one instance, pneumonia 
 in ten instances, pleurisy in three, and partly pneumonia, partly 
 pleurisy in the remaining five. 
 
 In almost all the fatal cases of carditis, either pleurisy or 
 pneumonia, or pleuro-pneumonia, were present.^ 
 
 1 The numbers 127 and 80 each include 5, or half of the cases in which the 
 date of the mischief was uncertain. 
 
 '•^ For illustrations of this fact, see Cap. YII, pp. l'JO-203, of this Treatise.
 
 284 INFLAMMATION OF THE LUNGS AND TLEVRM 
 
 Formidable, however, as these numbers are, the proportion 
 of cases in which pulmonary inflammation has arisen in acute 
 rheumatism, has been even gieater in the experience of others. 
 Thus Dr. John Taylor, of Iluddersfield, reports that of 11 cases 
 of rheumatic pericarditis, pleurisy was found in 5, and pneu- 
 monia in 5. In 4 of the latter there was pleurisy as well.^ 
 
 The physical symptoms of rheumatic inflammation of the 
 lungs and pleura, are such as are met with in ordinary pneu- 
 monia and pleurisy, and therefore need not be dwelt upon more 
 particularly, nor is there anything beyond the severity and in- 
 tractability of the disease, which calls for especial notice. But 
 in a diagnostic point of view, there is much which demands our 
 serious attention. Cases not unfrequently occur in w"hich no 
 external rheumatism exists, and in which, nevertheless, the 
 whole train of symptoms are doubtless attributable to the irri- 
 tation of the rheumatic poison. Just as cardiac aff"ection may 
 occur as the Jirst, and, for some time, the oniz/ local symptom 
 of rheumatism, so, also, I am persuaded, may bronchitis, pneu- 
 monia, and pleurisy. The cases referred to are usually char- 
 acterized from the first by a red coated tongue, profuse acid 
 perspiration, and by the strong empyreumatic odor of rheu- 
 matism ; and these symptoms are sometimes so striking, that 
 in two instances they have enabled me to predict the accession 
 of a well-developed attack of articular rheumatism."^ And al- 
 though the evidence of a rheumatic origin is seldom so strongly 
 
 1 " Medico-Chir. Trans.," vol. xxviii, p. 514. 
 
 2 A case of this sort has' recently occurred to me in the person of Thomas 
 Comber, who was admitted into the York ward of St. George's Hospital, under 
 my care, on the 2d of February, 1856, laboring under acute pneumonia. From 
 the very commencement of his attack, he was literally bathed in profuse acid 
 perspiration, emitting the peculiar odor of rheumatism, and his tongue was 
 excessively red and coated. So marked were these symptoms, that I ques- 
 tioned him as to the existence of rheumatic pains, and pointed out to the 
 pupils the peculiar character of the symptoms, as indicative of the probable 
 source of the attack, and as calculated to influence the treatment. Through- 
 out his sojourn in the hospital he had no external symptom of rheumatism, 
 but within three days of his discharge he was attacked with acute rheumatic 
 S'^-<»llin£r of the joints, and was readmitted into the hospital on the IGih of 
 March, under the care of Dr. Bence Jones, suffering from a well-marked attack 
 of acute rheumatism.
 
 AS A CONSEQUENCE OF ACUTE RHEUxMATISxM. 285 
 
 marked as in these instances, I am convinced bj the effect of 
 treatment in several suspicious cases, that the irritation of the 
 rheumatic poison is a much more fre([uent cause of pubnonary 
 inflammation than is generally supposed, and that its influence 
 cannot be safely disregarded. For in the treatment of rheu- 
 matic inflammation of the lungs, whether accompanied or unac- 
 companied by articular pain and swelling, it must ever be borne 
 in mind that the symptoms arise from no common local cause 
 of irritation. The mischief of which they are mere exponents, 
 is excited and kept up by a cause in its nature persistent, and, 
 indeed, coexistent, with the duration of the rheumatism, and 
 although we may modify the local action by remedies addressed 
 to the relief of inflammation, yet to arrest the progress of the 
 disease, means must be had recourse to calculated to promote 
 the neutralization and elimination of the rheumatic virus, which 
 is at once the source and maintenance of the disease. And 
 experience has proved what theory most justly leads us to an- 
 ticipate, namely, that blisters and derivatives are more efficient 
 than general venesection, and that, although local depletion 
 and full mercurial action may be needed for the relief of ex- 
 cessive local action, yet that no cure can be efiected without 
 due regard to the neutralization of the poison, and the promo- 
 tion of the various excretions by which its elimination is brought 
 about. Alkalies in full doses with opium and diuretics are as 
 useful here as in cure of the articular symptoms, and active 
 purging by the neutral salts is also of essential service. But 
 while employing blisters and the other remedies mentioned, the 
 serious nature of the local mischief must not be lost sight of 
 for a moment, and according as the- symptoms are indicative of 
 pneumonia, or of pleuritic inflammation, so must antimony or 
 calomel be administered. 
 
 In rheumatic pleurisy, however, as in rheumatic pericarditis, 
 it is necessary to observe the greatest circumspection in the 
 employment of lowering treatment; the patients are often pale 
 and exsanguine, and their strength is taxed to the utmost, not 
 only by the long duration of the disease, but by the want of 
 sleep and excessive perspiration which usually attend it. And
 
 286 INFLAMMATION OF THE LUNGS AND PLEURiE 
 
 if under these circumstances unnecessary depression be induced 
 by over activity in the treatment, a healthy lymph-eifusing in- 
 flammation may take on an unhealthy pus-generating char- 
 acter. 
 
 The following cases may serve to illustrate the violence of, 
 and extreme danger attendant upon, inflammation of the pul- 
 monary structures when occurring in the course of acute rheu- 
 matism : 
 
 Fred. Ford, aged 32, came under my care at St. George's 
 Hospital, on the 16th of November, 1850, sufi"ering from acute 
 rheumatism of four days' duration, principally afi"ecting the 
 right hand and elbows, which were red, tumefied, and extremely 
 painful. He appeared to have been going on well until the 
 morning of the 19th, when he began to complain of catching 
 pain on the left side of the chest, his pulse became sharp, and 
 his countenance expressive of anxiety. Auscultation revealed 
 a loud systolic mitral murmur, as also pleuritic friction and 
 aegophony at the seat of pain. He was a thin and sickly per- 
 son, a working tailor by trade, and three times a day had been 
 taking, by my orders, a niter draught, w'ith fifteen minims of 
 colchicum wine, ten drops of laudanum, and a drachm of potas- 
 sio-tartrate of soda. Directly he began to exhibit symptoms 
 of pulmonary and cardiac inflammation, twelve leeches w'ere 
 applied to the seat of pain, and their application was followed 
 by a blister; and to the draught were added twenty minims of 
 antimonial wine, and a drachm of tartarized soda; at the same 
 time, a pill was ordered to be taken every six hours, containing 
 three grains of calomel and one of opium. The leeches-bites 
 bled freely, the blister did its duty well, and within three days 
 he was brought under the influence of mercury; nevertheless, 
 the inflammation continued, modified perhaps in its course, 
 until the Avhole of the left side of the chest was dull on percus- 
 sion, and aegophony was audible only in the supra-scapular 
 region. Nor did the pleuritic inflammation alone proceed un- 
 checked. Rusty-colored pneumonic expectoration bore witness 
 to the existence of mischief in the lungs, and the stethoscope 
 revealed fine crepitation passing gradually over the inferior
 
 AS A CONSEQUENCE OF ACUTE RHEUMATISM. 287 
 
 third of the right lung. Five days more passed away, during 
 which a blister was again applied, and yet there was no material 
 amendment in the symptoms. I now became seriously alarmed 
 for his safety, for the breathing was hurried and oppressed, his 
 countenance anxious, and the pulse small and faltering. The 
 next day, however, ushered in a brighter epoch in the history 
 of his attack. The rheumatic symptoms were rapidly subsiding, 
 and with their cessation the more urgent chest symptoms began 
 to disappear : the breathing gradually became less embarrassed, 
 and the case proceeded favorably to its termination. Blisters 
 were repeatedly applied to the chest, diuretics were given freely, 
 and on the 23d of January, 1851, the breathing was fairly re- 
 established throughout the chest, and my patient had got rid 
 of his present distress, at the expense of a damaged mitral 
 valve, and an universally (?) adherent pleura. 
 
 Cases, hoAvever, not unfrequently occur, in which, either from 
 the extent and intensity of the pulmonary inflammation, from 
 the fearful mischief in other organs Avhich accompanies it, 
 or from the depressed condition or unhealthy constitution of 
 the patient, a fatal issue is almost inevitable. Dr. Latham 
 has put several fatal cases on record; and, among the sixteen 
 fatal cases of which I have given abstracts in a previous chapter, 
 no fewer than nine were accompanied by extensive and acute 
 pulmonary inflammation.^ A case of this sort was admitted 
 into St. George's Hospital on the 4th of March, 1839, under 
 the care of my colleague. Dr. Wilson. The patient, a servant- 
 maid, aged 32, by her own account, had been ill for three weeks 
 
 1 See Cap. VIII, of tliis Treatise. Subjoined is an account of tlie pulmonary 
 inflammation in the several cases. 
 
 Case I. Pneumonia on both sides of the chest, going on to partial hepati- 
 zation of the lungs. 
 " II. Pneumonia affecting both lungs, and double pleurisy. 
 " III. Pleurisy on both sides of the chest. 
 " V. Pleurisy on both sides of the chest. 
 " VII. Pleurisy on both sides of the chest. 
 
 " IX. Pneumonia on both sides, pleurisy on one side of the chest. 
 " X. Bronchitis affecting both lungs. 
 " XII. Single pleuris3^ ^ 
 
 " XV. Pneumonia of l)oth lungs going on to the production of gray 
 hepatization. Single pleurisy.
 
 288 INFLAMMATION OF THE LUNGS AND PLEURAE 
 
 before lier admission into the hospital. She was attacked 
 during the catamenial period by pains all over her, and shiver- 
 ings, with occasional heats and sweatings. She was also sick. 
 The pain then "fell on her chest," with much cough and thick 
 expectoration. A week afterward her wrists and knees became 
 swollen and red. When removed into the hospital, the joints 
 were no longer swollen, but she complained of excessive pain 
 beneath the sternum, increased on inspiration. "On the 6th 
 of March she was attacked bj a severe rigor, the first of a 
 long series of shivering fits, which afterward gave place to 
 periodical attacks of dyspnoea, in one of which the patient 
 expired on the 26th." The body was examined on the 27th, 
 twenty-six hours after death. There was considerable effusion 
 into all the serous cavities of the chest: "the pericardium con- 
 tained about eight ounces of fluid slightly flaked by lymph : a 
 little of the soft yellow deposit rested on the heart: the left 
 auricle Avas greatly distended by a tolerably firm coagulum: 
 its valvular surface was beset by numerous warty vegetations, 
 and the edges of the valve were much thickened and contracted. 
 From the regurgitation thus effected by a dam in the blood's 
 current, partial hemorrhage had followed in the lungs, which 
 exhibited many instances of the circumscribed apoplectic clot. 
 One entire lobe was in this way closed against air. It was of 
 peculiar interest in this case, that the warty vegetations were 
 likewise indigenous to the right side of the heart. They were 
 observed in great numbers on the auricular surface of the tri- 
 cuspid valve, some of them even projecting round into the 
 cavity of the ventricle. The other viscera were generally 
 healthy."^ 
 
 Another case, in which the pulmonary symptoms assumed 
 an equally grave aspect, fell under my observation in St. 
 George's Hospital in the year 1845. Frances Webster, aged 
 18, a thin delicate girl, Avhose father was a martyr to rheu- 
 matism, Avas admitted into the hospital on the J4th of March, 
 under the care of Dr. Wilson. At the age of 15, while recov- 
 ering from scarlatina, she had been attacked by acute rheu- 
 
 1 See the Report, hy Dr. Wilson, in the "Lancet" for November 16, 1844.
 
 AS A CONSEQUENCE OF ACUTE RHEUMATISM. 289 
 
 matism, and had ever since been subject, at short intervals, to 
 wandering pains in the limbs, unattended, however, by redness 
 or swelling. Eight days before her removal to the hospital, 
 she had experienced rigors, followed by dyspnoea, palpitation, 
 and catching pain in the cardiac region ; and on the day before 
 admission had begun to manifest external symptoms of rheu- 
 matism, Avhich showed themselves by inflammation of several 
 of the larger joints.^ On admission, coincidently with redness 
 and swelling of the joints, there existed endocardial and exo- 
 cardial inflammation. There' was extreme irregularity of the 
 pulse, Avith extended dullness on percussion in the prrecordial 
 region. The heart's sounds were distant and muflfled, and at 
 the base of the heart were both obscured by a loud to-and-fro 
 sound of friction. At the apex, however, a loud systolic bel- 
 lows murmur was distinctly audible. Small bleedings were 
 resorted to, a blister was applied to the chest, and saline medi- 
 cines, with antimony, were administered, while the system was 
 being brought under the influence of mercury. By degrees 
 the physical signs gave evidence of the salutary eff'ect of the 
 treatment employed, for the heart's sounds became clearer and 
 less distant, the dullness in the praecordial region less extended, 
 and the pulse steadier. At the same time the articular swell- 
 ings subsided, and everything seemed to promise a favorable 
 issue. But on the twelfth day after admission, the articular 
 inflammation recommenced, and with it a catching pain on the 
 right side of the chest, accompanied by pleuritic friction and 
 ajgophony, announcing the supervention of acute pleurisy. 
 Subsequently, an attack of a similar nature commenced on 
 the left side of the chest, and with it inflammation of the lung 
 itself. The poor girl's breathing was now exceedingly op- 
 pressed, her powers of life were manifestly failing, and her 
 back began to slough. Still, however, she lingered on, and 
 even survived an attack of peritonitis which supervened a few 
 
 ^ "Sometimes," says Dr. Williams, ("On Morbid Poisons," p. 10,) "when a 
 poison acts on many membranes, the usual order of attack is inverted." Such 
 appears to have been the case in the present instance, for the heart was evi- 
 dently attacked some days before the invasion of the joints.
 
 290 DISORGANIZATION OF THE JOINTS 
 
 days afterward. But on the 2Tth of April a fresh attack of 
 inflammation was set up on the left side, and she sank on the 
 28th, under the combined influence of her several maladies. 
 
 A post-mortem examination revealed, as was expected, a 
 heart not greatly enlarged, but presenting a pericardium almost 
 universally adherent, by means of recently eff"used lymph ; a 
 mitral valve fringed with beads and festoons of recent lymph 
 and fibrin ; a copious eff'usion of lymph and serum into the 
 pleural cavity on either side ; the left lung passing into a state 
 of red hepatization ; and bands of recent lymph, together with 
 turbid serum, the ordinary products of recent peritonitis, in the 
 cavity of the abdomen.^ 
 
 How full of painful interest are such cases ! how pregnant 
 with hints for our guidance and instruction ! ^o particular 
 organ or set of organs was alone the seat of morbid action. 
 The heart on its external and internal surface, the pleura on 
 either side of the chest, the lungs and the lining membrane of 
 the abdomen, the synovial membrane of the joints, the liga- 
 ments and the parts external to the joints, at once the seat of 
 active inflammation ! How widely spread must be the cause of 
 such extended mischief! how unlike the eff'ects of any local 
 agency ! No impartial inquirer can fail to admit the import- 
 ance of such cases, no zealous physiologist to recognize and 
 appreciate their intimate bearing on the true pathology of the 
 disease. 
 
 One other complication of acute rheumatism is deserving of 
 especial notice ; I refer to disorganization of the joints, which 
 sometimes ensues when the articular inflammation is stationary 
 for any length of time. Generally speaking, the liability to 
 this occurrence varies in inverse proportion to the number of 
 articulations affected, but there is always just ground for 
 anxiety, respecting the integrity of a joint, which, in spite of 
 treatment, remains swollen and painful unusually long. I have 
 seen so many cases of unequivocal rheumatism giving rise to 
 
 1 For further particulars respecting the autopsy of this case, see the '• Ab- 
 stract," at p. 191, of this Treatise, as also the '^ rost-mortcm Book' for 1845, 
 preserved in the Museum of St. George's Hospital.
 
 AS A CONSEQUENCE OF ACUTE RHEUMATISM. 291 
 
 acute lymph-effusing inflammation of the joints, and, in some 
 few instances, to suppuration, that I am convinced of the neces- 
 sity for the greatest vigilance in watching the progress of the 
 articular inflammation, and taking every precaution for its 
 speedy subjugation. When pain and swelling become fixed in 
 any particular joint, and continue there after the symptoms in 
 the other joints have subsided, there is always reason to fear 
 that inflammation has taken a deeper hold than usual of the 
 articular structures, has produced there some of its ordinary 
 ill effects, and if not arrested- will go on to ulceration of the 
 cartilages, and the production of a stiff joint. 
 
 The necessity for strict attention to the progress of the 
 articular symptoms of rheumatism cannot be enforced better 
 than by citing the particulars of one or two cases in which, 
 during life, there has been every token of threatening articular 
 disorganization, or every evidence after death of extensive 
 local mischief. 
 
 Ann Stevens, a thin delicate-looking girl, aged 18, became 
 a patient under my care, at St. George's Hospital, on the 14th 
 of September, 1850. She had been suffering nearly two weeks 
 from acute rheumatism, principally affecting the right hand and 
 wrist, which were swollen and inflamed. Other parts had been 
 temporarily affected, but the right wrist had remained swollen 
 throughout. A week passed away, and, though all pain had 
 ceased in other parts of the body, yet, in spite of fomentations, 
 her wrist remained as much inflamed as ever, and the pain was 
 aggravated by the slightest motion. Still I hoped to conquer 
 the disease by the agency of medicine addressed to the relief of 
 rheumatism, but as, at the end of a fortnight, she had shown 
 no signs of amendment, and mischief appeared imminent, I 
 judged it expedient to put some leeches on the joint, and to 
 folloAV their application by a blister, giving her at the same time 
 calomel and opium. This at once alleviated her suffering ; the 
 tension of the inflamed part was relieved, the redness subsided, 
 and, in the course of another week, the pain and the swelling 
 had been greatly subdued. Some pain, however, still continued, 
 so another blister was applied, and, subsequently, in order to
 
 292 DISORGANIZATION OF THE JOINTS 
 
 insure perfect rest, her arm was placed on a splint, and the 
 wrist was blistered as before. This completed what the first 
 local applications had eflfectuallj begun ; the pain subsided, 
 and there remained only thickening of the parts about the 
 joint, and some effusion, probably of thickened synovial fluid, 
 within the capsules. This was, after a time, removed by 
 absorption, under the influence of the compound Iodine lotion, 
 and she was discharged on the IGth of November, very little 
 stifi'ness of the joints remaining. 
 
 So also, in the case of Ann Conolly, aged 17, who was ad- 
 mitted into St. George's Hospital, on the 25th of August, 1847, 
 under the care of my colleague. Dr. Nairne. She had been 
 suffering one week from acute rheumatism, principally affecting 
 the hands and wrists, and at the time of her admission, the 
 wrist, and several of the smaller joints of the hands, were 
 inflamed and swollen. She was greatly out of health, but under 
 the use of purgatives, salines, and the mistura guaiaci of the 
 Pharmacopoeia, the pains and swellings had all subsided by the 
 3d of September, except those in the third finger of the left 
 hand, and the thumb of the right hand. In those parts the 
 inflammation continued unabated, and so obstinate did it prove, 
 and so severe in its nature, that crepitation could at last be felt 
 distinctly in the aff"ected joints. In spite of blisters and mus- 
 tard poultices, which were repeatedly applied, of colchicum, 
 which was administered internally, and of full mercurial action, 
 which was twice induced before the symptoms were entirely 
 subdued, the poor girl was not in a state to leave the Hospital 
 until the 3d of November, when she had very little motion in the 
 thumb, and her finger was anchylosed in a hent jjosition. 
 
 Some cases, however, do not issue so favorably; the patient 
 sinks either from the irritation of the articular inflammation, 
 or from the concurrence of some serious internal complication. 
 In such cases there has been found every stage of acute artic- 
 ular inflammation, from simple congestion to extreme capillary 
 injection of the aff"ected parts, with effusion of lymph and pus. 
 In the case of the young girl already referred to (p. 275) as 
 having been complicated by active delirium, " each knee-joint 
 
 I
 
 AS A CONSEQUENCE OF ACUTE RHEUMATISM. 293 
 
 contained rather more than a drachm of turbid, glutinous serum, 
 which was alkaline, highly albuminous, containing many oil- 
 globules and cells the size of pus-globules, having well-marked 
 nuclei, and of a specific gravity greater than the albuminous 
 liquid. Some cells were also seen three times as large as those 
 containing granular matter and nuclei. 
 
 " In the upper part of the cavity of each joint, a tliickhli 
 mass of fibrin an hicli and a half broad, and about the same 
 length, tvas lying. One of these masses was deeply stained 
 with red blood, but no vessels could be traced in it. On 
 removing these substances the synovial membrane at the iipper 
 jjart of each joint was seen to be intensely red, and highly vas- 
 cular, and to present the most striking contrast to the white, 
 shining cartilage in which no vessels could be traced, and 
 which was not altered in appearance. 
 
 " One elbow-joint was opened, and it contained a clear, glu- 
 tinous, synovial fluid, apparently without any cells in it."^ 
 
 In some instances inflammation has produced even more 
 disastrous consequences, having gone on rapidly to suppuration 
 and complete disorganization of the joint. A case in which 
 ulceration of the cartilages took place, has been recorded by 
 my colleague, Mr. Caesar Hawkins, in the " Lancet" for August 
 23d, 1851 ; and others are to be found in the various medical 
 journals. Within my own observation, five instances have 
 occurred, of three of which an abstract has been already given. ^ 
 The post-mortem appearances observed in Case IV may be 
 taken as a sample. In that case " the right knee and the left 
 wrist-joints were still swollen, and when cut into, were found 
 to contain large quantities of thick, viscid fluid, mixed with 
 lymph and pus. The sheaths of the tendons at the back of 
 both wrist-joints contained a quantity of thick puriform fluid. 
 
 1 St. George's Hospital Posl-morleni Book for 1850, preserved in the Museum 
 of the Hospital. 
 
 2 See Abstract of Cases IV,VII, and XVI, recorded in Cap. VII. In Case XIII 
 a large number of pus-globules were discovered by the microscope, but as t!ie 
 fluid contained in the joints appeared to be thickened synovia, containing pus- 
 globules, rather tlian a purely purident or sero-purulcnt fluid, it is probable 
 that suppuration was only just commencing at the time of the patient's death
 
 294 
 
 DISORGANIZATION OF THE JOINTS, ETC. 
 
 The left knee-joint contained a larger quantity of synovia than 
 natural, and the synovial membrane of this joint was slightly 
 increased in vascularity."' 
 
 As then very serious lesions may arise from rheumatic artic- 
 ular inflammation, even when the greatest caution is observed, 
 and, as such lesions are more likely to occur when the local 
 symptoms are neglected, it behooves us to do all in our power 
 for their relief, and to watch carefully for the earliest indica- 
 tions of commencing mischief. From the first, as already 
 stated, much comfort may be afforded by the application of 
 warm or tepid fomentations, and repeated experiments have 
 convinced me that none prove so efficient as the alkaline and 
 sedative solution, of which I have elsewhere given the formula. - 
 When this is fairly and fully employed from the first, artic- 
 ular mischief will rarely if ever happen. But in such matters 
 it is not prudent to run the slightest risk, and when inflamma- 
 tion attaches itself with more than usual obstinacy to any par- 
 ticular joint, leeches or a blister should be applied at once, and 
 repeated, if necessary, while the system is being brought under 
 the influence of mercury. By these means, and by perfect 
 rest, which is best insured by means of a splint, the pain will 
 be subdued, the swelling got rid of, and the integrity of the 
 patient's joints preserved. 
 
 } 
 
 1 For a detailed account of this case, with the dissection after death, see St. 
 George's Hospital Post-viortem Book for 1845, p. 218. 
 
 2 Page 119.
 
 CHAPTER XI. 
 
 ON RHEUMATIC GOUT. 
 
 Closely allied to rheumatism, yet presenting some of the 
 features of gout, is that obstinate, painful, and distressing mal- 
 ady, which is known under' the title of Rheumatic Gout.^ 
 Whether viewed in relation to the amount of present suffering 
 it inflicts, or to the permanent injury and distortion it entails, 
 it ranks among the most formidable of this class of disorders, 
 
 1 This form of disease has been described by Dr. Macleod under the title of 
 ■• Capsular Rheumatism ;" bj Dr. Todd under that of " Chronic Rheumatism of 
 the Joints ;" and by Dr. Adams, of Dublin, under that of '' Chronic Rheumatic 
 Arthritis." These appellations, however, appear to me objectionable, inasmuch 
 as they refer the local changes to rheumatism, with which they have no sort 
 of connection. Dr. Garrod objects to the title of Rheumatic Gout, and pro- 
 poses the term " Rheumatoid Arthritis." He states that we should be equally 
 justified in calling certain cases of scarlatina, or measles, by the compound 
 title of " Rubeolo-Scarlatina," as in applying the term Rheumatic Gout to the 
 disease under consideration. But this is simply an incorrect view. Rheu- 
 matic Gout is not a mere variety of Gout or of Rheumatism, nor is it a com- 
 pound of the two diseases ; it is essentially distinct from them both, has a 
 special pathology of its own, and requires a distinctive title. The term Rubeolo- 
 Scarlatina could only be applied legitimately to a disease bearing a strong 
 resemblance to Rubeolo and Scarlatina, yet having a separate and independent 
 existence. To such a disorder its application would be appropriate. On the 
 other hand, if the term Rheumatoid Arthritis were to be employed, a due regard 
 to our nomenclature would necessitate the disuse of the terms Gout and 
 Rheumatism, and the substitution of the titles " Gouty Arthritis'" and " Rheu- 
 matic Arthritis." 
 
 My own opinion in favor of the term " Rheumatic Gout" remains unshaken. 
 The titles of diseases are seldom used to indicate their pathology, but rather 
 as a means of establishing their identity. In this point of view, the terra 
 Rheumatic Gout is unexceptionable. It points to the class of diseases with 
 which the malady in question is closely allied, yet at the same time it is suffi- 
 ciently distinctive, and cannot be confounded with either Gout or Rheumatism. 
 Further, it has the great advantage of being already recognized, and extensively 
 used. Even Dr. Garrod has deserted his favorite bantling, " Rheumatoid Arth- 
 ritis," and has adopted the term " Rheumatic Gout" as the title of his l)Ook. 
 
 In truth, it is a most appropriate title ; and it is to be hoped the Profession 
 "will concur in limiting its application to the disease under consideration.
 
 296 RHEUMATIC GOUT. 
 
 Its symptoms are not only temporarih'^ severe, but often lead 
 to irremediable helplessness. 
 
 The natural history of rheumatic gout accords but little with 
 that of true rheumatism, and is equally inconsistent with that 
 of true gout. It differs from rheumatism in the frequency of 
 its attacks, and the increase exhibited at each recurrence in 
 the severity and obstinacy of its symptoms ; in invading the 
 small joints in preference to the large; in being more stationary, 
 and usually causing thickening and permanent enlargement ; 
 in never involving the heart or its membranes ; and in some- 
 times producing desquamation of th§ skin. In all these par- 
 ticulars it strikingl}'^ exhibits a gouty nature. But it is unlike 
 gout, in numbering among its victims the young, the middle- 
 aged, the slender, and the weakly ; in attacking women more 
 frequently than men ; in invading several joints simultaneously ; 
 and in being ordinarily unattended by dyspeptic symptoms. 
 In all these points its rheumatic nature is strongly marked. It 
 maintains, indeed, as its name implies, a place intermediate be- 
 tween the two disorders ; it is identical with neither, yet presents 
 some characteristics of both, and is, therefore, well described 
 by the popular, yet distinctive title of rheumatic gout.^ 
 
 In its acute, and apparently most terrible form, this disease 
 may be confounded with acute rheumatism ; but when carefully 
 examined, its history, symptoms, progress, and terminations, 
 all serve to illustrate its distinctive character. Referable, 
 without doubt, to some constitutional peculiarity closely con- 
 nected with perverted assimilation, it selects as its victims 
 either the weakly and unhealthy, in whom the natural excre- 
 tions are imperfect or deficient, or else fixes upon those who, 
 though usually robust, have been subjected to some cause of 
 mental or bodily depression. It is remarkably prone to aflfect 
 
 ' I shall presentlj- give the reasons which have led rae to believe that it is 
 essentially distinct from true rheumatism, and equally so from true gout; that 
 it has a special pathology, and demands a peculiar method of treatment j and 
 that, if regarded and treated as either rheumatism or gout, it will usually run 
 on unchecked in its course.
 
 RHEUMATIC GOUT. 297 
 
 the children of consumptive parents ;^ it attacks the offspring 
 of gouty or rheumatic persons whose health is impaired, and 
 whose nervous energy is exhausted by the labor and anxieties 
 of business ; it fixes upon the girl just arriving at puberty, in 
 whom the uterine functions are ill performed ; it invades the 
 stiffening articulations of the woman who has arrived at that 
 time of life which is marked by the cessation of the monthly 
 periods ; it shows itself during the state of debility which fol- 
 lows a miscarriage, or a difficult and protracted labor, more 
 especially when the labor has- been accompanied by flooding ; 
 it is a frequent attendant upon renal disease; upon the cachexia 
 produced by syphilis or gonorrhoea, or neglected mercurial 
 action ; and it is a common sequel of over-long suckling, of 
 excessive venery, of severe and long-continued mental exercise, 
 and of mental distress and bodily exhaustion. Neither ao-e 
 nor sex affords immunity from its invasion; but most commonly 
 it shows itself from the age of thirty-five onward ; and its ear- 
 liest attacks are usually seen in girls whose uterine functions 
 are suspended or ill performed.^ 
 
 Its attack, when acute, may be ushered in by considerable 
 fever, together with pain and aching of the joints, and after a 
 
 ' Of 119 patients of whom I have raade special inquiry on this subject, no 
 less than 23, or 1 in every 5-2, had lost a parent, or one or more brothers or 
 sisters by consumption. 
 
 2 In almost every instance which has fallen under my notice of its occurrence 
 in very early life, it has been either hereditary or else connected with disor- 
 dered uterine function. Within th ; last four years I have had under my care 
 no less than eleven girls, under eighteen years of age, suffering from this com- 
 plaint. In every instance, save one, the monthly periods were disordered, fa 
 the years 1851-2 I had two girls under my care, at St. George'.<( Hospital, of 
 the respective ages of fifteen and seventeen, whose joints were frighLfully dis- 
 torted by the disease. In the former the menses had first appeared at the age 
 of thirteen, but had only reappeared three times since; in the latter they had 
 been absent a year and a half, and their cessation was coincident with the 
 commencement of ill health. The first of these patients, at my earnest desire, 
 went, for four months, to Bath, and returned much benefited by her re.-idence 
 there. Dr. Haygarth's experience also led him to connect its appearance ia 
 women with irregularity of the catamenia, for he remarks, ('' Clinical .Medicine " 
 p. 18.3,) that "out of thirty-three women in whom he observed it, three only 
 were afHicted with it during the period of regular menstruation, and of these 
 one had suffered twelve abortions." 
 20
 
 298 RHEUMATIC GOUT. 
 
 time, some redness may supervene, just as in a paroxysm of 
 ordinary rheumatism. But more generally there is little ex- 
 ternal discoloration, and far less heat of skin, less furring of 
 the tongue, less bounding of the pulse, in short, less active 
 febrile disturbance, than in acute rheumatism ; and though the 
 skin may be moist, and the urine loaded with lithates, yet the 
 urine is less loaded than in a corresponding state of excitement 
 from true rheumatism, and the perspiration is less constant, 
 less sour-smelling, and less profuse. But the liver usually acts 
 more imperfectly than in genuine rheumatism, as is evidenced 
 by the yellowness of the complexion and the conjunctivae, the 
 yellowness of the fur on the tongue, and the paleness of the 
 alvine evacuations. 
 
 The form and the situation of the articular swellings present 
 well-marked peculiarities. Whereas the larger joints most 
 commonly suffer in true rheumatism, the small joints of the 
 hands are the parts most frequently affected in this disease ; 
 and when the knees, or other of the larger articulations are 
 attacked, the character of the swelling is peculiar and diag- 
 nostic. It is more circumscribed than the articular swelling of 
 acute rheumatism, and in its form and character indicates the 
 existence of effusion within the joint and the adjacent bursas 
 and tendons, rather than into the surrounding structures. In 
 the knee-joint this peculiarity is strikingly manifest. While 
 there is little if any effusion into the surrounding tissues, the 
 synovial membrane, full and distended, may be seen projecting 
 at those parts where the adjacent structures offer least resist- 
 ance, and if the two hands be placed one on either side of the 
 joint, fluctuation may be made perceptible to the touch. The 
 adjoining bursae, and the sheaths of the tendons, are also felt 
 as circumscribed swellings. Another peculiarity is, that the 
 local symptoms are less migratory and more obstinate in their 
 continuance, so that there is greater danger of disorganization 
 of the joints, or of thickening in their immediate vicinity. 
 Indeed, although the first activity of the articular inflammation 
 may be subdued by treatment more rapidly than under corre- 
 sponding circumstances in acute rheumatism, yet, in a subacute
 
 RHEUMATIC GOUT. 299 
 
 or chronic form, inflammatory action will often persist for 
 months, producing permanent and irreparable mischief. Nor 
 are the differences confined to the points already specified ; 
 they are strikingly marked in the nature of its complications. 
 It is unaccompanied by the frightful heart disease which proves 
 so fatal in acute rheumatism, but it has for its attendants in- 
 flammations of the eye, the pleurae, and the brain. 
 
 Sometimes, however, the diagnosis between acute rheuma- 
 tism and acute rheumatic gout is by no means easy. Indeed, 
 I entertain considerable doubt whether an attack which com- 
 mences as acute rheumatism, may not change its type under 
 certain conditions of treatment or constitution, and terminate 
 eventually in rheumatic gout. Certain it is, that I have seen 
 several cases characterized at first by all the most striking 
 features of acute rheumatism, by the thickly-coated tongue, 
 the loaded urine, the bounding pulse, the profuse, acid, sour- 
 smelling perspirations, and, moreover, by the peculiar redness 
 and inflammation shifting rapidly from joint to joint, and 
 aff"ecting the larger in preference to the smaller joints, in 
 which, after the first intensity of the attack has been subdued, 
 a different train of symptoms has arisen. The larger joints 
 have gradually obtained immunity from pain, but the small 
 joints of the hands have become painful, swollen, and, in spite 
 of treatment, permanently enlarged ; the articular inflamma- 
 tion, though less urgent in its character, has been extremely 
 obstinate in its continuance, and has lost its distinctive migra- 
 tory character ; the skin has been no longer bathed in prespira- 
 tion ; the urine no longer loaded ; and the pulse has changed 
 its character, and from being full and bounding, has become 
 soft and weak, or irritable. Thus I have repeatedly known 
 patients crippled by unequivocal rheumatic gout, which com- 
 menced, in the first instance, apparently as a sequel of acute 
 rheumatism. In two instances of this sort the patients, after a 
 time, came again under my notice, suff"ering from well-marked 
 rheumatic gout, which, in this second attack, had not been 
 preceded by symptoms of rheumatic fever. 
 
 When the disease assumes a chronic form, it admits of much
 
 300 RHEUMATIC GOUT. 
 
 more readj diagnosi?. Occurring sometimes after the subsidence 
 or partial disappearance of an acute paroxysm of the disorder, 
 but more commonly without any previous acute attack, it may 
 commence without any remarkable febrile disturbance while 
 the pulse is quiet, the tongue almost clean, and the urine 
 abundant, pale colored, and of low specific gravity. The 
 patient's chief complaint is of languor and loss of appetite, 
 with occasional chilliness, and pain and stiffness in the joints, 
 which soon become swollen from effusion into their synovial 
 cavities, and into the bursge and sheaths of tendons immediately 
 surrounding them. Sometimes, indeed, there are no dyspeptic 
 symptoms, and the patient declares that nothing disagrees with 
 him. In such cases the complexion is usually florid, the skin 
 acts freely, the tongue is clean, the action of the bowels regu- 
 lar, and the urine clear ; and the only noticeable indications of 
 declining health are fretfulness or irritability of temper, with 
 depression of spirits, coldness of the extremities, feebleness of 
 the pulse, and pale or almost colorless urine, remarkable for 
 the extreme lowness of its specific gravity. But more generally 
 the complexion is sallow and the skin sluggish, and evidence of 
 mischief is furnished by yellowness of the conjunctivae, consti- 
 pation of the bowels, a pale and unhealthy character of the 
 dejections, excessive flatulerfce after meals, turbidity of the 
 urine, feebleness of the pulse, and slow yet steady enlargement 
 of the joints — an enlargement which in many cases is unac- 
 companied by perceptible increase of local action, and appears 
 to depend upon a process allied to slow perversion of nutrition, 
 rather than to ordinary active inflammation. Yet so obstinate 
 does it generally prove in its continuance, and such thickening 
 does it produce in the periosteum covering the extremities of 
 the bones, in the ligamentous structures, in the synovial mem- 
 brane, and in the bursre and sheaths of tendons immediately 
 surrounding the joints, that more or less permanent stiffness 
 and enlargement remain long after all active disease has passed 
 away. A second or third attack brings out in relief this dis- 
 tinctive feature. The irritation of a poison which has been 
 attracted to the joint for a sufficient length of time to cause
 
 DIAGNOSIS OF THE DISEASE IN A CHRONIC FORM. 301 
 
 effusion into the synovial membrane, and thickening of the sub- 
 synovial areolar tissue, very seldom fails to excite more deep- 
 seated and more serious mischief. The cartilages with which 
 the structures in question are intimately connected are gen- 
 erally implicated sooner or later. Their nutrition becomes 
 affected, and gradual absorption of their structure takes place ; 
 and thus, after a time, the articular surfaces of the bone are 
 left bare and unprotected. But more than this. While the 
 ligaments which keep the extremities of the bone in apposition 
 are being stretched by the -fluid effused within the joint, and 
 the cartilages at the same time are gradually wasting, the 
 extremities of the bones themselves become irregularly en- 
 larged by expansion of their osseous tissue, and the deposit of 
 osseous matter around the joint. ^ A material alteration is 
 thus produced in the form, and oftentimes in the direction of 
 the joint. The fingers, for instance, which are very prone to 
 be affected, are drawn toward the ulnar or outer side of the 
 hand, and take a permanently oblique direction ; while the 
 enlarged, and partly dislocated extremities of the bones, more 
 especially of the metacarpal bones, project in every variety of 
 form, and constitute the " nodosities" which have been described 
 by Dr. Ilaygarth, in his " Clinical History of Disease."^ 
 Strange as it may seem, these changes in the form and direc- 
 
 1 " The great distinction of this process from ordinary iiiHammation con- 
 sists in this, that in the chronic rheumatic affection," as Dr Colles has well 
 remarked, '■ two very opposite processes are to be found going on at the same 
 time, viz. : absorption of the old bone and its cartilage of incrustation, with 
 deposition of new bony matter, while in the ordinary inflammation there would 
 be simply a gradual enlargement of the bone. It is worthy of remark that, 
 in malignant disease of the joints, and in strumous affections of thorn, both 
 connected with constitutional taint, there is the same tendency to the forma- 
 tion of exuberant osseous growths around the joints, while the articular 
 textures within are suffering destruction and decay." (Todd on " Rheumatism," 
 p. 169.) For beautiful illustrations of the changes thus produced in the joints, 
 see the Atlas which accompanies Dr. Adams's work on Rheumatic Gout. 
 
 * I am glad to find my views confirmed by Professor Rokitancky, who gives 
 it as his opinion, (" Pathological Anatomy," p 173,) that the changes in ihese 
 cases are not due to simple rheumatic arthritis. He believes them to have more 
 or less of a gouty origin, but I am inclined to regard them as referable to the 
 agency of a specific poison altogether distinct from, though closely allied to, 
 the materies morbi of rheumatism and gout.
 
 302 RHEUMATIC GOUT. 
 
 tion of the joints are strikingly similar on either side of the 
 body, each knobby enlargement on the one side having its 
 counterpart in the corresponding joint on the other, so that an 
 extraordinary symmetry of arrangement is exhibited in the 
 local manifestations of the disease. 
 
 In connection with this enlargement of the joints, there sel- 
 dom exists any deposit resembling the chalky deposit of gout : 
 indeed, it may be stated that no such deposit is ever found, 
 unless at some time or another the patient has been afflicted 
 Avith true gout. The first series of changes are usually con- 
 fined to an alteration in the nutrition of the parts affected, 
 which causes them to lose their natural brilliancy and elastic- 
 ity, and to become thickened, opaque, and altered in color. 
 After a longer period of exposure to the irritation of the rheu- 
 matic element, a further alteration of structure takes place ; 
 processes of thickened synovial membrane are seen dipping 
 down into depressions existing around the head and neck of the 
 bones;' or a dense ligamentous substance, resulting probably 
 from some peculiar alteration in the synovial membrane, is seen 
 interposed between the articulcating surfaces;^ or small irreg- 
 ularh'^-shaped cartilaginous bodies are found existing, either 
 loose within the joint, or attached to it by pedicles formed of 
 thickened synovial membrane;^ or the opposed surfaces of the 
 bones denuded by chronic wasting of the cartilages, and rend- 
 ered smooth by attrition upon each other, are found white, 
 glistening, and ivory-like in appearance.^ 
 
 • 8ee Dr. Adams's articles in the '• Cyclop;cdia of Anatomy and Physiology," 
 as also the Reports of Messrs. Adams, Canton, and Prescott Hewett, in the 
 '• Transactions of the Paihologrical Society of London " 
 
 '^ A case illustrative of this change in the synovial membrane will be found 
 in Sir Benjamin Brodie's "Observations on Diseases of the Joints," p. 11. 
 Specimens illustrative of this morbid appearance may be seen in the Museum 
 of St. George's Hospital. 
 
 ^ For a full description of the minute structure of these bodies, see a paper 
 by Mr. Rainey, quoted in the " Transactions of the Pathological Society of 
 London" for 1848-40, p 110 ; also Dr. Adams's treatise on Rheumatic Gout, 
 pp. .S1-.34. Some beautiful preparations, exhibiting these bodies in situ, may 
 be seen in the Museum of St. George's Hospital. 
 
 * This condition has been described and delineated by Cruveilhier, under 
 the title of " Qsure des Cartilages." Cases in point are recorded in Sir B. 
 
 \
 
 MODE OF DETERMINING THE NATURE OF THE DISEASE. 303 
 
 But in some cases, which in external appearance present 
 many of the characteristics of the disorder I am describing, 
 there exists a deposit, more or less extensive, of a white pul- 
 verulent matter. Sometimes this matter is deposited over the 
 ■whole extent of the articulating surfaces, so that the cartilages 
 appear smoothly incrusted by it ; at others, it is sparingly 
 sprinkled over their surface in the form of a fine white powder ; 
 at others, it is limited to a few parts only; and at others, again, 
 it not only covers their entire surface, but pervades their struc- 
 ture, and fills the cancelli of the subjacent bone.^ That this 
 deposit, which analysis has shown to consist of lithate of soda, 
 mixed occasionally with some lithate of potash, ammonia, and 
 lime, as also with chloride of sodium, and with phosphate and 
 carbonate of lime,^ is identical in composition with the deposit 
 which exists in gout, and that it occurs in those cases only of 
 rheumatic gout which in their external symptoms approximate 
 most closely to genuine gout, is susceptible of easy proof; and 
 it does not admit of doubt that its presence in the joints is con- 
 clusive evidence of the existence of true gout at some period or 
 another of the patient's life. But I cannot, therefore, admit 
 the conclusion, that the existence of such deposit is of itself 
 sufficient to mark such cases as examples throughout of true 
 gout; for it often occurs in persons who, in their younger days, 
 have been martyrs to rheumatic gout in its distinctive form; 
 and it sometimes coexists with those structural changes in the 
 joints which everybody admits to be dependent upon rheumatic 
 gout. Thus, among cases which do not diifer greatly from 
 each other in their external character, there are found, in some, 
 
 Brodie's work " On the Joints," ed. 4, p. 322, as also in the " Transac- 
 tions uf the Pathological JSociety.'' Specimens are preserved in the Museum 
 of St. George's Hospital. 
 
 1 See Report by Dr. Handfield Jones, in the " Pathological Transactions'' 
 for 1848-9. 
 
 '■* This was distinctly proved in some cases of Dr. Chambers's, as also in a 
 case of Mr. Stanley's, ofSt. Bartholomew's Hospital, (reported by Sir C. Scud- 
 amore, in his work on "Rheumatism," p. 351,) in which the deposit consisted 
 almost entirely of carbonate of lime. Specimens of the joints are preserved 
 in the Hospital Museum. For the result of several analyses of the ordinary 
 tophacious deposits, see Simon's "Chemistry," vol. ii, p. 4TT.
 
 304 RHEUMATIC GOUT. 
 
 extensive structural alterations in the joints, but no traces, 
 however slight, of earthy deposit; in others, the same altered 
 condition of the articulations is accompanied by an evident, 
 though scanty and irregular earthy doposit; Avhile in others, 
 again, the deposit is extensive, and the structural changes first 
 alluded to, comparatively small. In the more extreme examples 
 of the disease it is not difficult to determine whether the case 
 be one of gout or rheumatic gout, and to predict with tolerable 
 accuracy whether any deposit will or will not be discovered in 
 the joints after death ; but in some few instances the symptoms 
 are of such a hybrid character as to preclude the possibility of 
 arriving at any certain conclusion. Even dissection fails some- 
 times to disclose any strongly-marked difference between those 
 cases which are, and those which are not, accompanied by such 
 deposit ; for occasionally one joint may be found smeared over 
 with earthy matter, while another in the same patient, equally 
 enlarged, presents no appreciable amount of deposit. Of this 
 I have seen two instances ; and as it is quite possible for a gouty 
 tendency to be engrafted on an old rheumatic gout disposition, 
 or for a rheumatic gout tendency to arise in a gouty habit, I 
 have come to the conclusion that in such cases, which are very 
 rare, the disease has been at one time rheumatic gout, at another 
 more strictly gouty in its nature, and that the difference in the 
 results observed after death has arisen from the prevalence 
 of each form of disease at different periods of the patient's 
 life. 
 
 I trust it is made sufficiently clear, by the above statement, 
 that the disease should not be regarded as of a hybrid charac- 
 ter, or, in other words, made up in part of rheumatism, in part 
 of gout. It is my firm conviction, that just as the true rheu- 
 matism and true gout do both sometimes manifest themselves at 
 different periods of life in the same individual, so rheumatic 
 gout may arise in a person who either has been, or may here- 
 after become, subject to true rheumatism or true gout, and that 
 it has no connection with either of these diseases, beyond that 
 which attaches to it in virtue of its being a constitutional dis- 
 order, producing local manifestations in the joints. Not only
 
 MODE OF DETERMINING THE NATURE OF THE DISEASE. 305 
 
 does analysis of the blood, and of tlie fluid eflused into the joints 
 in these cases, when well marked and distinctive, prove the ab- 
 sence of lithic acid, the poison of gout, as a cause of the articu- 
 lar inflammation and enlargement, but the rare occurrence of 
 an}'' goutj deposit in the joints, in cases answering to my de- 
 scription of rheumatic gout, renders it manifest, even to a 
 superficial observer, that the presence of true gouty symptoms 
 il a mere coincidence, and by no means essential to the exist- 
 ence of the disease. On the other hand, analogy furnishes 
 strong grounds for the belief- that the articular mischief is not 
 due to the presence of lactic acid, or whatever may be the mate- 
 ries morbi in true rheumatism, while the rapidity with which 
 structural disorganization of the joints supervenes, even when 
 the local action is apparently least acute, and when the gen- 
 eral symptoms are certainly not indicative of febrile disturb- 
 ance, is a further proof that it is essentially distinct from true 
 rheumatism, as typified in rheumatic fever, or in the ordinary 
 chronic form of the disease. Indeed, the circumstances under 
 which rheumatic gout occurs, the extraordinary obstinacy of its 
 symptoms, the peculiar alteration in the structure of the joints, 
 which forms its most characteristic feature, and the. class of 
 remedies by which it is most successfully combated, all seem to 
 indicate a close connection with some peculiar constitutional 
 taint.^ The able researches of Dr. Gairdner^ have rendered it 
 extremely probable that true gout is in some way connected 
 with a variation in the relative quantities of urea and uric acid 
 in the system, and hereafter it may be discovered that rheu- 
 matic gout is dependent on some other perversion in the rela- 
 tive proportions of the constituents of the blood. And if this 
 be so; if, in short, the disease be due to a disordered condition 
 of the blood essentially distinct in its character from that which 
 gives rise to pure gout or to pure rheumatism, we are bound in 
 accordance with sound pathology to separate it from the dis- 
 eases it so much resembles, and with which it is sometimes in- 
 timately blended ; to trace out its peculiarities ; and to estab- 
 
 1 See note, p. 301. '^ On Gout.
 
 306 RHEUMATIC GOUT. 
 
 lish, if possible, by chemical demonstration, its claim to be con- 
 sidered a special disorder. 
 
 When the superficial joints are attacked by this disease, the 
 symptoms already described will generally enable us to recog- 
 nize its true character. But all joints are liable to its invasion, 
 and when those which are deep seated suiFer, the diagnosis is 
 much more diiBcult and uncertain. This is more particularly 
 the case when the hip-joint is the part implicated. Local paiH, 
 or a sense of stiflTness unaccompanied by heat, or by any ma- 
 terial constitutional disturbance, is usually the first symptom to 
 attract attention, and oftentimes considerable alteration in the 
 joint will have occurred before steps are taken for its relief. 
 As the disease progresses, the pain becomes more constant and 
 severe, and is felt most acutely when the weight is thrown on 
 to the affected joint. After a time, other symptoms arise de- 
 pendent on the changes progressing within the joint. For, in 
 the hip, as in the other joints, the disease is attended by the de- 
 posit of ossific matter around the head of the bone, with grad- 
 ual wasting of the cartilages, and eburnation of the opposed 
 articulating surfaces. And, as the bony deposits take place 
 irregulyly, the shape of the acetabulum and head of the femur 
 is altered, as is also, not unfrequently, the position of the head, 
 in relation to the neck of the bone. This, together with ab- 
 sorption of the cartilages, leads to so much shortening of the 
 affected limb, and renders rotation of the thigh so difficult, that 
 the patient walks lame, and presents an exceedingly awkward 
 appearance. The nates of the affected side become flattened, 
 and the muscles of the thigh, in some measure, atrophied from 
 want of use ; the foot is everted, and sometimes the toes only 
 can be placed on the ground ; while, from the difficulty or im- 
 possibility of rotating the leg, circumduction of the limb is 
 rendered necessary. 
 
 The symptoms just described, point unequivocally to mis- 
 chief in the hip, yet, as this affection is usually limited to the 
 one hip, and rarely extends to other articulations,^ the unwary 
 might be led to attribute the mischief to some other and a 
 ^ See " Cyclopaedia of Anatomy and Physiology," article *^Hip."
 
 TREATMENT OF THE ACUTE FORM. 307 
 
 purely local cause. But careful inquiry into the history of the 
 case will seldom fail to unveil the mystery. Generally the 
 patient will bo found to have suffered from rheumatic gout at 
 some former period ; or to have experienced pain recently in 
 some of his other joints ; or, possibly, to have had slight tem- 
 porary swelling in the knee, or in one of his toes or knuckles; 
 and thus a clew to the nature of the disease will be obtained at 
 once, and may be safely acted on. Indeed, such a discovery is 
 of great practical importance, inasmuch as it often leads to the 
 employment of remedies addressed to the relief of constitutional 
 derangement, when otherwise the treatment might have been 
 purely local. 
 
 The treatment required in the acute form of rheumatic gout 
 differs from that of rheumatism, in that, from the character of 
 the persons attacked, it need seldom be actively antiphlogistic, 
 and from the inflammation of the joints being more stationary, 
 and the danger of structural disorganization greater, there is 
 more necessity for the application of leeches, blisters, and 
 fomentations to the inflamed parts. General venesection is 
 rarely, if ever, needed in this form of disease, even when most 
 acute, and opium, as was pointed out by Dr. Corrigan,^ is of 
 far less importance, than in genuine rheumatism. Even alkalies 
 are not needed in such full doses as in acute rheumatism, and 
 when so employed, are apt to prove depressing ; but given in 
 moderate quantity with colchicum, small doses of antimony, 
 and alterative doses of blue pill or calomel, aided by an occa- 
 sional warm or vapor bath, some mild purgative, topical appli- 
 cations to the joints, and strict attention to diet, are usually 
 sufficient for the relief of its more active symptoms. • 
 
 When speaking of the treatment of acute rheumatism, T en- 
 tered fully into the consideration of all the circumstances which 
 indicate the employment of these various remedies, and which 
 render their use inadmissible, and I do not know that anything 
 
 1 "There is one form of acute rheumatism," he says, ''in which the opiate 
 treatment will cause disajjpointment," it is that in which, " when rheumatism 
 does appear, it is not genuine rheumatism, but a combination of gout with 
 rheumatism." (" Dublin Medical Journal," vol. xvi, p. 267.)
 
 308 RHEUMATIC GOUT. 
 
 will be gained by a reiteration of cautions which hold good as 
 well in this form of disease as in that we were then consider- 
 ing. Colchicum' and alkalies are as necessary here as in gen- 
 uine rheumatism, and as the chylopoietic viscera are generally 
 sluggish, and the secretions much deranged, energetic medical 
 interference is needed to restore them to a healthy condition. 
 But in the administration of remedies, the greatest care should 
 be taken not to depress the system unnecessarily; if in genuine 
 rheumatism this caution is needful, much more so is it here, 
 where the disease occurs in the weakly or cachectic, and ex- 
 hibits a remarkable tendency to pass into a chronic form. 
 Whether mercury and purgatives, or colchicum be employed, 
 care must be taken so as to administer the medicines as to 
 remedy defective secretion, eliminate the poison, and restore a 
 healthy state of assimilation without lowering the patient, and 
 exhausting his strength. The whole energy of his constitution 
 may be needed to bear up against the protracted irritation 
 arising from chronic inflammation of the joints, and even if he 
 escape articular disorganization, nothing, in my experience, so 
 greatly tends to endanger recovery, nothing assists so much in 
 perpetuating the rheumatic state, as over-active and depressing 
 treatment. 
 
 Sometimes, however, a slightly antiphlogistic treatment 
 seems imperatively called for, by the obstinacy of the local 
 symptoms, and the long continuance of febrile disturbance. 
 The cases alluded to are characterized by more than ordinary 
 derangement of the digestive function, an unhealthy condition 
 of the intestinal secretions, and excessive sluggishness of the 
 • liver. There is acidity of the stomach, with a foul tongue, and 
 a disagreeable sour taste in the mouth, and the dejections are 
 dark colored and offensive, or else pale and deficient in healthy 
 bile. In some cases, the action of a brisk emetic so completely 
 modifies the character of the secretions, and exercises so much 
 influence for good, as to render active treatment unnecessary ; 
 
 1 In some examples of this form of disease I liave found the tincture of the 
 flowers of colchicum extremely beneficial, even when other preparations have 
 failed.
 
 REMEDIES WHICH PROVE MOST USEFUL. 309 
 
 but when it fails to do so, it is especially needful to get rid of 
 the disordered accumulations in the bowels, and to stimulate the 
 whole secreting apparatus of the intestines by alteratives and 
 laxatives judiciously administered. For this purpose nothing 
 answers better than small doses of blue pill, or of calomel in 
 combination with opium and acetous extract of colchicum, fol- 
 lowed by a senna or rhubarb draught, containing carbonate of 
 magnesia to neutralize any free acid existing in the stomach ; 
 and if small bleedings be employed,^ and antimony given, while 
 a full action is thus maintained, the intensity of the febrile 
 action is speedily mitigated, and the patient is brought into a 
 atate to benefit by other remedies. Cases which prove intract- 
 able by alkalies, colchicum, and mercury, yield readily to their 
 influence after the febrile action has been subdued by the means 
 just alluded to.^ 
 
 In some instances, lemon-juice proves a valuable ally in the 
 treatment of this form of disease, more especially when the 
 patient is cachectic or scorbutic, and has lived almost exclu- 
 sively on animal or farinaceous food, in foolish dread of whole- 
 some vegetables. Whether it be by its direct influence on the 
 digestion, or by supplying some needful material to the blood, 
 lemon-juice, in many cases, undoubtedly assists in accelerating 
 a cure. In hospital practice, as well as in private life, I have 
 had repeated opportunities of noting this fact, and in several 
 instances the improvement which has followed has been most 
 marked and rapid. Therefore, whenever the sponginess of 
 the gums or the history of the patient leads me to suspect the 
 existence of one of the conditions referred to, I order lemonade 
 made with the juice of one or two lemons to be taken daily as 
 a beverage, in addition to other remedies. It is of little or no 
 service when the urine is clear, pale, and abundant, but when 
 it is scanty, high colored, and loaded, it so often proves useful 
 
 ^ Not more than from ^iv to §vj of blood sbould be taken in these cases. 
 
 ^ Dr Graves, in alluding to this class of cases, remarks, "Cases of rheu- 
 matic arthritis, attended with prolonged excitement of the circulation and 
 copious sweating, are generally found to exhibit an intractable chronicity, and 
 too often terminate in rendering the unfortunate patient a cripple for life." 
 (•' Clinical Medicine," ed. 2, vol. i, p. 488.)
 
 310 RHEUMATIC GOUT 
 
 in promoting diuresis and effecting a salutary change in the 
 system, that, Avhatever the prior history of the patient, 1 gener- 
 ally recommend its being taken in the manner pointed out. If 
 its flavor rises in the mouth long after it has been taken, it 
 manifestly disagrees, and its use must be discontinued ; but if 
 not, its administration should be steadily persisted in. 
 
 In most instances the early and assiduous employment of 
 appropriate fomentations Avill prevent the occurrence of articu- 
 lar mischief, and obviate the necessity for more active local 
 remedies. If, directly inflammation of a joint is set up, that 
 joint be kept at rest and constantly bathed in a warm solution 
 of potash and opium, I am satisfied, from repeated observation, 
 that no other toj)ical application will be needed. But the 
 neglect of this simple and rational precaution exposes the 
 structures to the mischievous eff'ect of excessive and protracted 
 irritation, and renders probable the occurrence of actions 
 requiring other measures for their subjugation. 
 
 No doubt can exist as to the vast importance of protecting 
 the joints from permanent mischief, and therefore, when the 
 disease, from whatever cause, does show a disposition to fix 
 itself in a particular locality, immediate steps should be taken 
 for its relief. Local depletion, if had recourse to early, is 
 folloAved by speedy abatement of pain and swelling, and even 
 in subacute and lingering cases, or at a later period of the 
 attack, will still aff'ord considerable benefit. But it is usually 
 necessary to employ counter-irritation in order to eff'ect a com- 
 plete removal of the mischief. When much eff"usion or thick- 
 ening has taken place, something more than mere local depletion 
 is needed to restore the parts to a healthy condition. After 
 cupping and leeches have fairly done their work in unloading 
 the congested vessels and arresting the further progress of 
 eff'usion, blisters maintain the good efi"ects produced, and 
 remove the evil consequent on the action which has already 
 taken place. A cure which is impracticable by leeches alone, 
 becomes practicable and easy by the joint application of leeches 
 and blisters. 
 
 When once it becomes necessary, from the nature of the local
 
 APPROPRIATE REMEDIES. 311 
 
 mischief, to have recourse to such remedies, they can hardly 
 be employed too vigorously or too constantly. Half a dozen 
 leeches should be applied for several successive days, and 
 should be followed by blisters, repeated until all symptoms of 
 mischief shall have subsided. In the mean time the affected 
 parts should be kept perfectly quiet. If the wrist be implicated, 
 a splint should be applied, and fastened on by bandages passed 
 over the fingers and round the arm, above the seat of inflam- 
 mation. While perfect freedom from jnotion is thus insured, 
 the wrist itself, uncovered, is' open for examination, and ready 
 for the application of remedies. In like manner should the 
 knees, the ankles, or the elbows be involved, it is often of 
 service to adopt some such measures as those just alluded to, 
 in order to insure repose. 
 
 There is one class of remedies which, in acute rheumatic 
 gout, as in many cases of genuine rheumatism, are frequently 
 of essential service ; I mean vapor and hot-air baths, and warm 
 baths of various descriptions. They promote perspiration to 
 an extraordinary degree, and unload the system without greatly 
 depressing it. Hence in those instances which are marked by 
 harshness and dryness of the skin, they prove of inestimable 
 value. One species of bath, which from the nature of the case 
 it is difficult to make use of during a paroxysm of acute rheu- 
 matism, may be employed in this complaint with great advant- 
 age, namely, the warm bath rendered alkaline by the addition 
 of a pound of the carbonate of soda or carbonate of potash. 
 The value of this auxiliary in combating the disease, has been 
 ably pointed out by Dr. Wright, of Birmingham ;^ and within 
 my oAvn experience many cases which have long resisted oi'di- 
 nary treatment, have yielded readily as soon as this alkaline 
 bathing has been commenced. It certainly possesses virtues 
 which do not attach to the simple warm bath, and I believe its 
 peculiar efficacy is attributable in part to the local action of 
 the salt in stimulating the action of the skin, and in part to 
 absorption of the alkali into the blood. Repeated on alternate 
 days, or daily when the skin is sluggish in its action, a bath of 
 
 1 Lectures published in the " Medical Times" for June, 1847.
 
 812 RHEUMATIC GOITT. 
 
 this description appears not only to mitigate the severity of the 
 local symptoms, but to promote a free secretion from the skin, 
 the liver, and the kidneys, and so to be conducive to the resto- 
 ration of health. 
 
 The foregoing observations have been confined to the treat- 
 ment of the disease as it is met with in the more vigorous, and 
 in those who heretofore have been free from its invasion. In 
 such persons there is evidence of active febrile disturbance ; the 
 skin is often hot, the tongue furred, the urine loaded ; and as 
 the excretory organs are in a condition to answer to the stimu- 
 lus of medicine, nothing answers better to check the further 
 formation of the poison, to promote the elimination of that 
 which has been already generated, and to restore a healthy 
 state of assimilation, than the treatment above described. But 
 we are more frequently called upon to administer relief to those 
 whose enlarged and distorted joints give abundant evidence of 
 long-standing mischief, or whose sallow complexion attests the 
 long continuance of general derangement. To such persons 
 the remedies already specified afford but little and only tempo- 
 rary abatement of suffering. In them the whole conditions of 
 the case are altered. The skin is usually cool, and is moist and 
 clammy, or, if not, is harsh and unperspiring ; the tongue is but 
 slightly coated ; the pulse weak and irritable ; and the urine 
 abundant, pale colored, and of Tow specific gravity, sometimes 
 containing a trace of albumen ; all of which symptoms point 
 most significantly to the presence of a small quantity only of 
 the poison, and to a defective condition of the excretory organs 
 as the principal cause of its accumulation in the system. Hence 
 medicines which prove serviceable to the one class of patients, 
 are found useless to the other whose excretory organs are 
 faulty or inactive. They often produce alarming depression 
 without fulfilling the object of their administration. In these 
 cases, therefore, another class of remedies has to be called to 
 our aid. As, by giving diuretics and other medicines which 
 act as direct stimuli to the kidneys and liver, we are unable 
 permanently to affect the character of the secretions, we must 
 endeavor to improve the tone of the system generally, and so 

 
 AS IT APPEARS IN THE WEAKLY AND CACHECTIC. 313 
 
 to render the excretory organs more eflBcient in their action. 
 Meanwhile we must relieve, as best we may, the more urgent 
 symptoms of the disease, by acting upon the skin and making 
 it perform the extra duty which devolves upon it in consequence 
 of the inactivity of the other organs. 
 
 The means by which these ends may be accomplished assume 
 different aspects under different circumstances. In general, a 
 combination of bark, sarsaparilla, iodide of potassium, and 
 liquor potassse, when aided by change of scene and air, active 
 exercise, judicious bathing, and constant friction, proves one 
 of the most efficient means of rousing the dormant energies of 
 the system, and restoring the power of the excretory organs.^ 
 In many instances the happiest results are obtained from this 
 plan of treatment when steadily and properly persevered in. 
 I have seen case after case, in which, under this treatment 
 continued for some months, the patient's general aspect has 
 improved, his complexion has become clearer, his appetite more 
 regular, the pulse stronger ; and in which, coincidently with 
 this injprovement in the health, there has been a corresponding 
 alteration in the character of the excretions, and in the severity 
 of the rheumatic symptoms. The urine has regained its normal 
 specific gravity, the alvine evacuations have reassumed their 
 healthy bilious appearance, and all active articular symptoms 
 have subsided, leaving only some thickening about the tendons 
 and ligaments. 
 
 Sometimes, however, when the appetite is indifferent, the 
 tongue clean, the urine pale, and the skin clammy, alkalies, 
 even when combined with tonics, do not appear to mitigate the 
 disorder. Indeed, they seem to lower the general tone of the 
 system, and thus indirectly to aggravate existing mischief. 
 The appetite, already indifferent, fails altogether ; a sense of 
 exhaustion and nervous depression ensues, and the pains and 
 swellings increase. Under these circumstances, the mineral 
 
 1 The formula} I usually employ are: 
 Tincturae Cinchonae co., 5Jss ; or else Liquoris Potassaj, n^xlv. 
 Liquoris Potassaj, v\kI\- ; Potassii lodidi, gr. v-x ; 
 
 Potassii lodidl, gr. v-x ; Extract! Sarzae, 5J '• 
 
 Decocti Sarzse co., ^iij, ter die. Decocti Cinchonae, 3x1, ter die. 
 
 21
 
 314 RHEUMATIC GOUT. 
 
 acids in full doses, combined with bark, quinia, strychnia, or 
 other vegetable bitters, and aided bj the daily use of the cold 
 shower bath, prove in many cases valuable and trustworthy 
 remedies.^ Indeed, I know of no combination of remedial 
 agents in the persevering use of which I place so much con- 
 fidence. Many patients, whose symptoms have long resisted 
 the influence of^uaiacum, iodide of potassium, colchicum, and 
 every vaiiety of alkaline and alterative treatment, and who 
 have been brought to me crippled by long-standing pain and 
 enlargement of their joints, have regained their health, and 
 got rid of their disease, under this treatment. The principal 
 conditions essential to its success are, that the remedies shall . 
 be tolerated or assimilated by the stomach ; and that during 
 the period of their administration the secretions shall be care- 
 fully watched, and a gentle purgative and alterative pill given, 
 if turbidity of the urine, or a pale or abnormally dark color of 
 the alvine evacuations, appears to indicate biliary or renal de- 
 rangement. If the biliary secretions are healthy, and the 
 stomach does not rebel, cod-liver oil is a useful adjunct to the 
 mixture. 
 
 In some instances, however, the stomach is so much de- 
 ranged, that it will not tolerate bark or other tonics ; and, 
 under such circumstances, an emetic forms an admirable pre- 
 cursor of other remedies, and does much toward preparing 
 the way for their administration. On several occasions I have 
 known the appetite to return, the digestive function improve, 
 and the excretory organs reassume their due activity, under 
 the influence of medicines which, prior to the action of an 
 emetic, had proved quite inoperative. 
 
 In most of the cases in which tonics disagree the liver is very 
 
 1 The following are formulas I often employ-, viz. : 
 Acidi Nitrici ; Or, Sulphatis Strychnia;, gr. ^ig ; 
 
 Acidi Hydrochlorici, aa tHiij-v ; Acidi Nitrici ; 
 
 Quinaj Disulphatis, gr. ij ; Acidi Hydrochlorici, aa 'm.'ij-v j 
 
 Tincturae Arnicte Montanae, Tt^xxv ; Tinct. Arnica; Montanae, TUxxv ; 
 Syrupi Aurantii, 3''iss : Syrupi Aurantii, 5"'ss; 
 
 Decocti Cinchonae, §j ; Infiisi Aurantii, Co., §j : 
 
 M. ft. Haustus ter die sumendus. M. ft. Haustus ter die sumendus.
 
 TREATMENT OF THE CHRONIC FORM. 315 
 
 sluggish in its action, and the secretions of the bowels are 
 unhealthy ; consequently, during the administration of these 
 remedies, it is necessary to employ some gentle laxative. Calo- 
 mel, and indeed every form of mercury, is apt to prove exceed- 
 ingly depressing, so instead of having recourse to its adminis- 
 tration, it often becomes advisable to prescribe a pill containing 
 four or five grains of oxgall, or else a morning draught, con- 
 sisting of some light bitter infusion, together with aloes and 
 extract of taraxacum. Sometimes taraxacum is of such service, 
 that I rely upon it even to a greater degree, and prescribe an 
 infusion made with an ounce and a half of the finely sliced root, 
 to eight ounces of boiling water, to be taken before breakfast 
 every morning; or else administer from half a drachm to a 
 drachm of the extract three times a day, in combination with 
 alkalies and the infusion of gentian, adding, when necessary, a 
 little tincture of rhubarb, or half an ounce of the compound 
 decoction of aloes. 
 
 In cases which are not accompanied by much hepatic di^- 
 rangement, and in which there is a want of tone in tlie system, 
 with depression of spirits, coldness of the extremities, and fre- 
 quent clammy weakening perspiration, the greatest benefit is 
 often derived from the cautious use of the shower bath. In- 
 deed, among the younger sufferers from this complaint, I know 
 of no single remedy so generally efficacious. Even when, un- 
 der ordinary circumstances, the patients lack sufficient vigor to 
 withstand its shock, it may be often made available for their 
 relief by their taking it while standing in a warm bath of the 
 temperature of 98°, in which they have been previously im- 
 mersed, with the view of stimulating the cutaneous circulation. 
 But those persons who have long been victims to this disease, 
 whose conjunctivae are yellow, and who present other symptoms 
 of biliary derangement, derive greater benefit from the use of 
 the vapor or hot-air bath cautiously employed, than from any 
 other external remedy. To them the shower bath is too de- 
 pressing; it chills and exhausts them, and is not followed by 
 the salutary glow of reaction which ensues after its employ- 
 ment in the younger or less weakly. The warm bath, too, if
 
 316 RHEUMATIC GOUT. 
 
 frequently employed, proves equally depressing, and often fails 
 in giving rise to that flow of perspiration wliich is found so efli- 
 cacious as a relief to the sluggislily-acting liver and kidneys ; and, 
 although a sulphuretted and alkaline bath,' or a simple alkaline 
 bath, if cautiously employed and steadily persisted in, is often 
 efficacious, it yet proves slow in producing its salutary eff"ects. 
 But the vapor or the hot-air bath, if not made use of too fre- 
 quently, and persisted in for too long a period, unloads without 
 greatly depressing the system. It rapidly produces copious 
 perspiration, and the skin thus stimulated to vicarious action, 
 throws off a vast quantity of excrementitious matter which for 
 some time has been accumulating in the blood. Considerable 
 relief is thus obtained during the interval wh.ch must elapse 
 before the medicine can fulfill its work of invigorating the sys- 
 tem, and restoring the functions of the various excretory organs. 
 In eff"ecting this salutary change in the constitution, the 
 iodide of potassium is particularly serviceable, and, therefore, 
 unless it prove depressing, I seldom fail to recommend its ad- 
 ministration in three or four grain docs. But sometimes, if the 
 appetite is pretty good, the circulation at the same time languid, 
 and the skin inactive, the patient experiences greater relief 
 from its exhibition in combination with the mistura guaiaci, 
 than with the mixture before alluded to. If, in such a case 
 there be much languor and debility, and bark be indicated, it 
 is more desirable to add a drachm of the volatile tincture of 
 guaiacum to the bark mixture, than to substitute guaiacum en- 
 tirely for the cinchona. If, again, there be much irritability of 
 the stomach, and the bark induce nausea or febrile disturbance, 
 quinia is an admirable and eff"ective substitute, and may be ad- 
 ministered either with or without sulphate of magnesia, accord- 
 ing to the exigencies of the case. The addition of fifteen or 
 
 1 The subjoined formula, by Messrs. Planche and Boullay, makes an excel- 
 lent artificial Sulphuretted Bath : 
 
 Sulphide of Sodium or Potassium, ^iij ; 
 
 Carbonate of Soda, 5'j ] 
 
 Chloride of Sodium 5'jj 
 
 Sulphate of Soda, §j ; 
 
 Distilled Water, Oj. Mix, and then add to the mixture 
 20 gallons of Water, at the temperature of 98° Fahrenheit.
 
 TREATMENT OF THE CHRONIC FORM. 317 
 
 twent}' minims of the dilute sulphuric acid of the " Pharmaco- 
 poeia " is often of the greatest service. By such variations in 
 the combination of th(5se remedies, relief may be obtained in 
 most instances, even when it has been sought in vain from the 
 exhibition of colchicum, calomel, and the whole class of medi- 
 cines which prove beneficial in acute cases, occurring in per- 
 sons of a more healthy constitution. 
 
 Occasionally, however, when the patients are pale and ex- 
 sanguine, some ferruginous preparation proves a more efficient 
 stimulus and tonic than bark and sarsaparilla. The Mistura 
 Ferri Composita of the "Pharmacopoeia," the Sesquioxide of 
 Iron, the Ferri Potassio-Tartras, the Ferri Ammonio-Citras, 
 and the old-fashioned steel wine are all excellent preparations, 
 and may be administered in combination with other medicines, 
 according to the circumstances of the case. In some instances, 
 exceeding benefit is derived from the combination of iron with 
 cod-liver oil. A drachm of the syrup of iodide of iron, or fif- 
 teen drops of the muriated tincture, combined with three 
 drachms of the oil, has often proved, in my hands, a most val- 
 uable remedy ; and in no single instance in which its adminis- 
 tration has appeared advisable, has the slightest ill eff"ect re- 
 sulted from its exhibition. But throughout the period of its 
 administration, it is necessary to maintain a free action of the 
 skin, and to pay particular attention to the bowels. For if the 
 skin's action be sluo-^ish, or the alvine evacuations deficient in 
 quantity, the patient becomes heated, and the articular symp- 
 toms are aggravated in consequence. A very slight purgative 
 is usually sufficient to maintain regularity of the bowels, and 
 nothing answers better than an occasional pill composed of 
 soap, ipecacuanha, rhubarb, and aloes, with now and then the 
 addition of a small dose of colchicum.' 
 
 1 The following are pills I frequently employ, and have found exceedingly 
 useful : 
 
 Ipecacuanhae, gr. jss; Or, Ipecacuanha?, gr. jss ; 
 
 Saponis Castiliensis, gr. iv ; Pilula; Hydrarg., gr. j ; 
 
 Pil. Rhei Co., gr. iij ; Pilulio Rhci Co., gr. iij ; 
 
 Ext. Aloes Aquosi, gr. j. M. ft. Ext. Colchici Acet., gr. ij. M. ft. 
 
 Pilulae ij, quarum suiaantur j, Pilulae duae, quarum sumantur j, 
 
 vel ij, hord somni. vel ij, horA somni.
 
 318 RHEUMATIC GOUT. 
 
 There are other remedies, however, which may be resorted 
 to with a fair prospect of success, even when all ordinary med- 
 icines have failed ; among which I may'mention an infusion of 
 the leaves of the Fraxinus excelsior. Few remedies have been 
 more highly praised by those who have had recourse to its as- 
 sistance, and few certainly are less known, or less generally 
 employed. Indeed, in England its antirheumatic properties 
 are so little known, that I have searched our medical literature 
 in vain for the record of a single case in which its remedial 
 powers have been tested. This is the more remarkable because 
 it has been a favorite remedy with the peasants of Auvergne, 
 and other parts of France, for above half a century, and for 
 some years past has attracted the attention of the Profession 
 on the Continent. So long ago as the year 1852, Messrs. 
 Pouget and Peyraud published a very interesting account of its 
 curative virtues.^ These gentlemen assert, as the result of 
 their experience, that " the infusion of the leaves is perhaps a 
 true specific, combining with the most powerful curative action, 
 the advantage of not giving rise to any of the dangers or in- 
 conveniencies which result from the use of colchicum." "It 
 causes neither nausea, sickness, general discomfort, nor depres- 
 sion," but "generally at the end of four or five days, and sometimes 
 sooner, the pain, redness, and swelling have sensibly diminished 
 in intensity, or have even disappeared." In muscular rheu- 
 matism and in other forms of the disease it is also spoken of as 
 an excellent remedy. 
 
 My own experience does not warrant my speaking in such 
 unqualified terms of its curative powers, but it does justify my 
 stating that some cases are greatly benefited by its agency. I 
 have already met with several instances in which the disease, 
 after resisting ordinary remedies, has yielded to an infusion 
 made with one ounce and a half or two ounces of the leaves to 
 half a pint of water, combined witli such other medicines as the 
 peculiar circumstances of each case demanded. Moreover, the 
 patients who are most benefited by its administration are the 
 very persons on whom colchicum is almost useless on account 
 1 See the '■ Union Medicale," Nov. 27, 1852.
 
 TREATMENT OF THE CHRONIC FORM. 319 
 
 of its depressing or purgative action. Thus its remedial 
 action has been displayed most strikingly in persons already 
 exhausted by the disease — in persons with a disordered condi- 
 tion of the stomach, liver, and bowels, subject to profuse, 
 clammy perspiration on the slightest exertion ; whose urine is 
 at one time scanty and turbid, at another abundant, pale, and 
 of low specific gravity. In such persons, it appears to stimulate 
 the whole secreting apparatus, and to give tone to the digestive 
 organs ; it invigorates the system and checks the enfeebling 
 sweats; and certainly, in .some instances, is productive of 
 effects which are sought in vain from quinine and other bitters. 
 
 At present, my own experience of its administration is not 
 sufficiently extended to enable me to speak with confidence as 
 to its modus ojyerandi. In some few instances I have given it 
 uncombined with other remedies, and have been unable to per- 
 ceive any effect from its exhibition beyond that of gradual im- 
 provement of the health, and abatement of the pain and swell- 
 ing. Occasionally, it has given rise to some slight temporary 
 relaxation of the bowels, but more generally it has proved 
 without purgative action, and has not appeared to exercise any 
 decided influence over the secretion of the kidneys. Indeed, 
 its curative effects have been displayed at times when I was 
 able to perceive so little real alteration in the condition of the 
 excretions, that I have been led to regard its efficacy as de- 
 pendent on a specific alterative influence exerted over the pro- 
 cess of assimilation. Just as colchicum exerts what may be 
 termed a specific curative action, quite independently of its 
 action as a sedative or eliminative, so also, I believe, does the 
 Fraxinus excelsior, quite independently of its action as a tonic. 
 But let the explanation of its mysterious agency be what it 
 may, the fact remains that, administered with due regard to 
 the condition of the patient, the infusion of the leaves proves 
 a valuable remedy in certain cases of rheumatic gout, and in 
 those especially which are characterized by want of tone in the 
 system, and by an inordinate and unhealthy action of the 
 skin. 
 
 In strong contrast with the action of the remedy whose vir-
 
 320 RHEUMATIC GOUT. 
 
 tues we have just discussed, stands that of another medicine 
 which proves a faithful ally in many obstinate cases of rheu- 
 matic gout. I allude to arsenic. It must have been within 
 the experience of every medical man to meet with instances of 
 rheumatic gout marked by extreme inactivity of the skin. The 
 patients referred to suffer greatly from cold, and rarely, if ever, 
 perspire, however warmly they may be clad, however active the 
 exercise they take, and however great the heat to which they 
 may be subjected. Such cases are always more than usually 
 obstinate, and are thoroughly intractable to ordinary remedies. 
 Now in these instances arsenic will often furnish the requisite 
 stimulus to the system. Whatever its precise mode of action, 
 whether by rousing the activity of the capillary system, by ex- 
 citing cutaneous exhalation, or by imparting fresh tone and 
 vigor to the nervous system, and thus indirectly improving as- 
 similation, most certain it is that in a large proportion of the 
 cases referred to, improvement is manifested from the very date 
 of its administration. The languor and depression which char- 
 acterize the disease pass off; the complexion improves; the 
 skin loses its dryness and harshness; the excretions reassume 
 their healthy character ; the patient gains flesh, and the rheu- 
 matic or gouty sj'mptoms subside. Therefore, not unfrequently 
 when other remedies have failed, I liave had recourse to its as- 
 sistance, and although in some instances it has not fully rea- 
 lized my expectations, I have never had reason to regret its 
 administration. Given in moderate doses immediately after 
 meals, it rarely produces the slightest discomfort, and even 
 when it does give rise to temporary nausea, all unpleasantness 
 may be got rid of by suspending its administration, and then 
 diminishing the dose. If the urine be turbid, I usually pre- 
 scribe from eight to fifteen minims of the liquor potassee 
 arsenitis in combination with the acetate and bicarbonate of 
 potash, whereas if the urine be clear and of low specific gravity, 
 or if the mineral acids bo indicated, I order from ten to twenty 
 drops of the liquor arsenici chloridi, either alone or in combi- 
 nation with bark and hydrochloric acid. By thus varying the 
 form in which it is given, according to the different circum-
 
 TREATMENT OF THE CHRONIC FORM. 321 
 
 stances of tlie case, by watching the patient carefully during 
 the period of its administration, and by jealously guarding 
 against constipation, not only may this medicine be employed 
 with a fair prospect of affording relief which would be other- 
 wise unattainable, but the patient may be securely guarded 
 against the disagreeable effects which are caused by its action 
 when it is given incautiously or improperly. 
 
 Unlike many other remedies which prove useful in certain 
 cases of rheumatic gout, arsenic speedily influences the system, 
 and I have rarely met with an instance in which improvement 
 has resulted from its administration if some symptom of amend- 
 ment has not been manifested within a fortnight or three weeks 
 from the date of its first exhibition. Indeed, the only excep- 
 tions to this rule have been eases in which, from the peculiar 
 circumstances attending them, it was deemed inexpedient to 
 begin by giving more than a very small dose of the remedy — 
 a dose insufficient to produce a speedy result. This of itself is 
 a great encouragement to the physician to test its remedial 
 power in obstinate cases which seem likely to be benefited by 
 its action, and from the marvelous effects which I have wit- 
 nessed as a result of its exhibition, I feel justified in stating 
 that no case of rheumatic gout can be regarded as incurable, 
 on which its influence has not been fairly tried. ^ 
 
 Another remedy which I am unwilling to pass by without a 
 brief notice, is the Arnica Montana, or Leopard's Bane. In 
 Germany and in other parts of the Continent it is extensively 
 used internally, as a stimulant and diaphoretic; and in our 
 own country, as I am informed, it occupies a conspicuous place 
 in some of the quack remedies for gout and rheumatism. But 
 I have been unable to find any record of its use internally by 
 
 1 While these pages were passing through the press, my attention has been 
 directed to a remarkable case in point, recorded by Mr. Watson, of Cotting- 
 hara, in Yorkshire. The patient, a man sixty years of age, had been a martyr 
 to the complaint nearly twenty years. Crippled, helpless, and exhausted, he 
 seemed likely at no distant period to fall a victim to the disease. Within a 
 month after the first dose of the arsenical solution, he slept comfortably, ate 
 heartily, and was able to walk to church, a quarter of a mile distant. (See 
 "Association Med. Journ.,"' Jan. 19, 1856.)
 
 322 RnEUMATIC GOUT. 
 
 professional men in England, and, as far as I am aware, it hap 
 not been so employed except by myself. I am the more anx- 
 ious therefore to give the result of my experience as to its 
 action. 
 
 The class of cases in which it has afforded me the greatest 
 assistance is that which comprises patients who are feeble and 
 exhausted, whose skin is cool, whose pulse is weak and slow, 
 and whose urine is of low specific gravity. Its operation 
 appears to be that of a nervine stimulant and diaphoretic. It 
 increases the nervous force, rouses the circulation, and so pro- 
 motes more perfect assimilation and a more healthy action of 
 the different excretory organs. To these properties, I believe, 
 it owes its value as an adjunct to other remedies in the class of 
 cases just referred to. For the same reason it fails to exercise 
 a beneficial influence in cases characterized by nervous excita- 
 bility, with a quick pulse, heat of skin, and turbid urine. In 
 such cases it is apt to produce headache, nausea, or even 
 vomiting, wakefulness at night, and other symptoms of dis- 
 turbance of the nervous system. But let its modus operandi be 
 what it may, I have so often observed marked benefit from its 
 administration, that I cannot doubt as to the expediency of 
 employing it in appropriate cases. Given in the form of tinc- 
 ture or infusion,* in combination with cod-liver oil, vegetable 
 bitters, and alkalies or the mineral acids, according to the 
 nature of the case, it often proves extremely serviceable, and 
 produces effects which are sought in vain from the same class 
 of remedies, unaided by its stimulating action. 
 
 There is yet another class of cases, however, in which none 
 of the remedies hitherto mentioned are of much avail. I allude 
 to those wdiich have arisen in sequel of syphilis or gonorrhoea. 
 Such cases oftentimes do not occur until five or six months 
 after all primary venereal symptoms have disappeared ; and so 
 unwilling are the patients to believe that their former ailment 
 has any connection with their present attack, that it is some- 
 
 1 Of the tincture in common use, tt^xx to T^^xxx may be given as a dose, or 
 from 3iv tu 51 of an infusion prepared by macerating 3^j o' the flowers or of 
 the root in Oj of boiling water.
 
 TREATMENT OF THE CHRONIC FORM. 323 
 
 times difficult to elicit an admission as to the possibility of the 
 existence of a venereal taint. Yet so obstinate do some such 
 cases prove until appropriate remedies are administered, and 
 so readily do thej yield when the treatment is directed against 
 this presumed cause, that there cannot be a doubt as to their 
 venereal origin. In all public institutions, cases of this sort 
 are of frequent occurrence; and I have had reason to believe 
 that even in private practice they are more numerous than is 
 commonly supposed. Sometimes, indeed, where mercury has 
 been taken freely for the cure- of the original malady, and has 
 been pushed to salivation, the rheumatic cachexia is connected, 
 I believe, Avith the effect of mercury on the system rather than 
 with any remains of the venereal poison ; and in such instances 
 I have usually found that bark and sarsaparilla, combined with 
 full doses (gr. v to x) of iodide of potassium, and aided in their 
 action by an occasional vapor bath, have sufficed to eradicate 
 the disease ; but where, as not unfrequently happens, the pri- 
 mary syphilitic sores have been followed by ulceration of the 
 throat, cutaneous eruptions, or other secondary symptoms, I 
 have found nothing so useful in restoring health and ridding 
 the patient of his rheumatic gout as the biniodide of mercury 
 in combination with bark, the compound decoction of sarsapa- 
 rilla, and a generous diet. The same may be said of the disease 
 as it occurs in sequel of gonorrhoea. The iodide of potassium, 
 though often jiseful when administered in full doses, seems in 
 these cases insufficient of itself to arrest the mischief, but when 
 given in conjunction with a drachm and a half or two drachms 
 of the liquor hydrargyri bichloridi it speedily produces a bene- 
 ficial result. Case after case has come under my care at St. 
 George's Hospital in which the combined influence of iodine 
 and mercury has arrested the disease, after it had long with- 
 stood the action of these remedies exhibited separately. 
 
 As soon as the disease has yielded, and general debility only 
 remains, nothing proves more useful than a combination of 
 iodide of potassium with the syrup of iodide of quinine and iron ; 
 and this or some other form of tonic should be taken for some 
 weeks after all pain has subsided, with the view of guarding 
 against the recurrence of the disease.
 
 824 RHEUMATIC GOUT. 
 
 Thus, then, while attending to the condition of the internal 
 organs, the practitioner should administer one or more of the 
 remedies already mentioned, according to the varying circum- 
 stances of the case. But he should not neglect to provide in 
 other ways for the relief of the local symptoms and the elimi- 
 nation of the poison which has heen already generated. He 
 should call to his aid such external applications as have the 
 power of lulling pain and maintaining warmth in the affected 
 parts, of exciting free cutaneous action, and of promoting the 
 absorption of any matters which may have been effused. The 
 first-named indication may be readily fulfilled by employing 
 the opiate and alkaline fomentation, mentioned in the chapter 
 on the treatment of acute rheumatism.^ If the joints be wrapt 
 up in flannel saturated by the aforesaid solution, a genial glow 
 and perspiration are induced, and the pain is speedily relieved. 
 Even if there be no local redness or swelling, it is desirable to 
 clothe thickly with cotton wool all parts in which pain or un- 
 easiness is felt. By this simple expedient much unnecessary 
 suffering is prevented, and the patient, thus enabled to sleep 
 without having recourse to opiates, escapes the wear and tear 
 which inevitably result from long-continued pain, and is placed 
 in a position to profit by any measures calculated to invigorate 
 the constitution and restore a healthy state of assimilation. 
 
 Sometimes, even when these expedients fail, relief is afforded 
 by the topical application of a leaf of tobacco. Care should be 
 taken in selecting a fine leaf of true Virginian tobacco : its 
 main ribs or fibers should be taken out in order that the leaf 
 itself may fit close to the skin, and then, after being steeped 
 in or moistened with hot water, it should be placed round the 
 joint, and covered with oiled silk or thin gutta-percha. On 
 several occasions I have known this application afford speedy 
 relief. 
 
 Among other expedients for promoting the restoration of 
 health, may be mentioned, the constant use of friction, and full 
 daily ablutions. Those who are subject to rheumatism are well 
 aware of this important fact, and rarely fail to maintain, by 
 
 1 See p. 119.
 
 TREATMENT OF THE CHRONIC FORM. 325 
 
 means of the flesh brush, that unobstructed condition of the 
 skin's pores which is essential to free cutaneous transpiration, 
 and so to the elimination of the morbific matter. Nothing, 
 indeed, proves more conducive to the cure of rheumatism or 
 rheumatic gout, which has passed into a chronic and inactive 
 form. 
 
 But there are some local consequences of the disease, for the 
 relief of which the measures just alluded to prove utterly 
 inefficient. After all local symptoms of inflammation have 
 subsided, and the swellings have in most parts disappeared, 
 there oftentimes remains some thickening about the joints, or 
 an effusion into the capsules, the bursse, or the sheaths of ten- 
 dons, which resists all ordinary attempts to produce its absorp- 
 tion. Sometimes the knee-joint is the refractory part, and if 
 80, repeated blistering, followed by the application of mercurial 
 ointment to the blistered surface,' proves an effectual method 
 of stimulating the absorbents and getting rid of the obnoxious 
 secretion. But sometimes these measures fail in their effect, 
 and it frequently happens that some of the small joints of the 
 fingers to which blisters cannot be readily applied, or the 
 sheaths of tendons, or the bursas in the immediate vicinity of 
 the joints, are the parts which call for remedial intervention, 
 and then it is usually expedient, if not necessary, to have re- 
 course to some other mode of relief. In such cases liniments 
 and embrocations- have been recommended, and, in some 
 instances, considerable benefit has been derived from those of 
 a terebinthinate and oleaginous nature. But, generally, such 
 applications possess little virtue beyond that which attaches to 
 them in consequence of the friction which accompanies their 
 use ; and far greafer benefit will be usually obtained from the 
 local ap])lieation of iodine to the affected joints, than from the 
 whole of this class of remedies. The usual practice has been 
 
 1 " The doctrine of a preliminary constitutional affection being absolutely 
 necessary in order to obtain the specific action of mercury on any particular 
 organ, is wholly untenable ; while, on the other hand, there is a host of evi- 
 dence to prove that locally applied it produces a primary and distinct effect, 
 totally independent of its action oa the general economy." (Dr. Graves's 
 " Clinical Medicine,'" ed. 2, vol. i, p 490.)
 
 826 RHEUMATIC GOUT. 
 
 to paint the affected parts with the compound tincture of iodine, 
 or even with a stronger application, consisting of a drachm of 
 iodine, and a drachm and a half of iodide of potassium, dis- 
 solved in an ounce of rectified spirit, daily or twice a day if the 
 skin will bear it, until the effused fluid is entirely absorbed. But 
 these lotions generally produce smarting and desquamation of 
 the cuticle, and not unfrcquently vesication after the second or 
 third application ; so that, although they may prove useful as 
 counter-irritants, they cannot be of any service as absorbents. 
 Some persons, therefore, have preferred the iodide of potassium 
 ointment, or cod-liver oil containing iodine in solution, both of 
 which arc far less irritating in their nature. But the most 
 useful form in which iodine can be applied, and one which I 
 would strongly recommend to the Profession, is in very weak 
 solution, combined with glycerin, to prevent its drying.^ The 
 advantages which this possesses over all other applications are, 
 that it does not irritate the skin, if due precaution be observed 
 in its employment ; that it may be applied without intermission 
 for weeks, or even months, if necessary ; that it is readily 
 absorbed, and produces the specific topical action of iodine, 
 without uneasiness or inconvenience to the patient; and that, 
 as the glycerin prevents its drying, the lint or rag on which 
 it is applied need be wetted only once in the twenty-four hours. 
 By the aid of this lotion, with the addition occasionally of a few 
 grains of bichloride of mercury, forming a soluble biniodide, I 
 have been often enabled to reduce swellings of the joints, which 
 for months had resisted every other plan of treatment; and on 
 several occasions have had the satisfaction of restoring the use 
 of limbs which had been pronounced hopelessly crippled by 
 competent medical authorities.* • 
 
 ^ Subjoined is the form of lotion I usually employ : 
 
 Tincturae lodinii Composite, 5''j~3^j- 
 Glycerin), §iiiss ; 
 Aqua; Desiillatse, ^iv. 
 M. ft. Lotio. 
 To this I often add Hydrargyri Bichloridi, gr. iv-vj, forming a soluble 
 Biniodide of Mercury. 
 
 2 For a remarkable case in point, see case of George Wood, in " Hospital 
 Case Book'' No. 2, for Nov.. 1857, p. 14.5. This man contracted the disease ia 
 ladia, and had been discharged from the army as incurable.
 
 TREATMENT OF THE CHRONIC FORM. 327 
 
 Another very useful application, more especially when the 
 smaller joints are principally implicated, is an ointment con- 
 taining a drachm of calomel, or from four to six grains of the 
 bichloride of mercury, and two drachms of iodide of potassium, 
 to an ounce of lard. In several cases I have seen the thicken- 
 ing and enlargement yield to these remedies steadily perse- 
 vered in, after having long withstood the action of iodine 
 uncombined with mercury. In some instances, however, 
 greater benefit is derived from the application of the emplast. 
 araraoniaci c. hydrargyro, or- soap plaster with iodine, than 
 from the ointments just referred to. 
 
 When the larger joints have been affected, and thickening 
 and stiffness remain after the more fluid parts of the effusion 
 have been absorbed, a different mode of treatment is often- 
 times necessary. The parts no longer require the powerfully 
 absorbent influence of iodine or mercury, but they need the 
 stimulating action of friction combined with the relaxing and 
 deobstruent effect of local warmth and perspiration. In some 
 instances, the cold douche, followed by friction, and subse- 
 quently by the wet bandage, proves the most effectual method 
 of restoring motion to the joint ; in others, douches of steam 
 or hot water, followed by the wet bandage or warm fomenta- 
 tions, frequent inunction with some bland oil, or better still, 
 with cod-liver oil holding iodine in solution, repeated daily 
 rubbing, the warmth, support, and gently stimulating influence 
 of various plasters, and the use of galvanism, are the means 
 best calculated to effect the desired object. 
 
 But sometimes, in addition to enlargement and stiffness, there 
 exists some actual contraction of the limbs. It then becomes 
 necessary to adopt some means not only to relieve the joint, 
 but to loosen the ligaments and set free the tendons on which 
 the contraction of the limb depends. For this purpose forcible 
 yet gently applied extension of the limb must be employed. If 
 at an early stage of the complaint this precaution is observed, 
 all permanent contraction may be surely prevented, and even 
 at a later stage, when the contracted tendons seem almost to 
 require the surgeon's knife for their relief, a judicious combi-
 
 32S RHEUMATIC GOUT, 
 
 nation of local bathing, with manual friction and frequently 
 repeated extension of the limb, will often render operative 
 interference needless. Bj means such as these, I have been 
 enabled on several occasions to get rid of contractions of some 
 years' standing ; and it is by these or ver^' similar measures, 
 that certain irregular practitioners in this country and on the 
 Continent have acquired a reputation for the cure of enlarged 
 and contracted rheumatic joints. In all cases time is an essen- 
 tial element in the production of a favorable issue ; no change 
 will be manifest for many weeks, — it may be for two or three 
 months after a course of treatment is commenced; and even 
 when the stiffness begins to yield, the progress toward cure 
 will not be rapid. Therefore, before undertaking the manage- 
 ment of such a form of disease, it is always advisable to explain 
 the circumstances fully to the patient, in order that the treat- 
 ment may not be commenced unless he resolves to give it a fair 
 trial. So fully has experience convinced me of the inutility of 
 half measures on these occasions, that 1 now make a point of 
 refusing to take charge of patients so afflicted, if they declare 
 themselves unwilling, or, from circumstances, unable, to sub- 
 mit to at least a three months' course of treatment. Even this 
 period will seldom suffice for a cure, and any plan of treatment, 
 however judicious, if persisted in only for a shorter time, will 
 assuredly fail in its object, and not only cause disappointment 
 to the patient, but bring the physician into unmerited disre- 
 pute. 
 
 One of the simplest and most efficient methods of exerting 
 gradual extension of the limb, is by the use of a smooth in- 
 clined plane as a leg-rest. The apparatus can be made by any 
 carpenter or upholsterer. It consists of a piece of smooth or 
 polished mahogany, or other wood, about a yard in length, and 
 nine or ten inches in diameter, supported at its lower extremity 
 by a piece of wood, or leg, of sufficient height to raise it about 
 four inches from the ground, and at its upper end by a similar 
 piece of Avood of sufficient height to elevate its edge to a level 
 with the chair on which the patient is seated. When the con- 
 tracted limb is placed on this inclined plane, the weight of the
 
 GENERAL RULES IN REGARD TO DIET, ETC. 329 
 
 leg forces the heel downward, and thus produces gradual 
 extension. The force thus exerted is such that it cannot be 
 borne without discomfort for longer than twenty minutes or 
 half an hour ; but if the leg-rest is resorted to for that period 
 three or four times in the course of the day, and manual fric- 
 tion employed at the same time, or immediately afterward, a 
 marked change will be observed in the limb within the space of 
 a month or six weeks. If the stiflfness and contraction be of 
 long standing;, the steam douche should be used to relax the 
 parts before the leg is placed on the rest, and the joint, after 
 being thoroughly rubbed, should be covered with an iodine 
 plaster or the emplasticum ammoniaci cum hydrargyro spread 
 on wash leather, as in this way as much progress is made in the 
 course of a week as would result in a fortnight without this 
 assistance. In one instance I was enabled by these means, 
 persevered in for a period of nine months, and aided in their 
 effects by the occasional use of stimulating and absorbent em- 
 brocations, to straighten a leg which had been contracted 
 during the space of four years and a half. Of course, if bony 
 anchylosis, or distortion of the knee, has taken place, success 
 cannot attend our efforts, however judiciously directed, and 
 perseveringly employed ; but when, as is usually the case, the 
 contraction depends upon simple gluing together of the struc- 
 tures, external to the joint, with thickening of the capsule, and 
 possibly some remains of effusion within its cavity, or into the 
 bursas external to the joint, I see no reason for despair as to 
 straightening the limb, however long contraction may have 
 existed. 
 
 One subject, and that by no means an unimportant one, still 
 remains to be noticed. The imperfect condition of the assimi- 
 lating function requires the observance of the strictest rules of 
 diet. The food should be wholesome and nutritious, but not of 
 an over-stimulating character, and whether fish, or flesh, or 
 fowl be taken, it should be simply drest, and eaten sparingly 
 and at regular hours. With it may be taken some well-cooked 
 vegetable, though in a very small quantity, as tending to pro- 
 mote acetous fermentation ; and for the same reason salads and 
 22
 
 830 RHEUMATIC GOUT. 
 
 pickles should be avoided, as also beer, sugar, and all sweets. 
 More specific injunctions can hardly be laid down axiomati- 
 cally ; but, as a general rule, I would assert with Lord Bacon, 
 " it is a safer conclusion to say, ' this agrccth not well with me, 
 therefore I will not continue it;' — than, 'I find no ofi"ense of 
 this, therefore I may use it.' "^ 
 
 The above, and other similar cautions respecting diet, are so 
 generally admitted as essential, that it is unnecessary to insist 
 on them more strongly. But there is one point on which the 
 same general feeling does not exist, and as I am thoroughly 
 convinced of its importance, I wish to draw special attention to 
 it. Tea and cofi'ee, and water, are not usually included among 
 the articles on which the physician feels called upon to give 
 specific injunctions, or the patient to exercise ordinary common 
 sense. The sufi'erer from rheumatism and rheumatic gout, who 
 denies himself every culinary luxury in the hope of getting rid 
 of his troublesome enemy, permits himself at dinner to drink 
 water to satiety, and at breakfast and tea to sip cup after cup 
 of his favorite beverage, until his thirst be appeased or his 
 stomach incapable of further distention. Now, although water, 
 coffee, and tea are not prejudicial when taken in moderation, 
 yet, in large quantities they oppress tfie 'stomach, dilute the 
 gastric juice, and exert a baneful influence on the process of 
 digestion. No person in health can long indulge in inordinate 
 quantities of liquids at meal times with impunity, and to per- 
 sons whose digestive organs are impaired, they are little less 
 than poisons. They may prove grateful, or indeed useful, as 
 diluents, if taken in moderate quantity, when the meal is three 
 parts finished, but at an earlier period they should be taken 
 very sparingly, as if taken freely they are decidedly prejudicial. 
 
 There are many exceptions, however, to these rules respect- 
 ing diet, which it is necessary to point out clearly, inasmuch as 
 the recovery of the patient may depend upon their full and 
 practical recognition. They occur chiefly among those sufferers 
 from rheumatic gout who present a clean tongue, a cold and 
 clammy skin, and a very feeble pulse. In them, a spare diet 
 » Bacon's " Wisdom of the Antients." " Essay on the Regimen of Health."
 
 GENERAL RULES IN REGARD TO DIET, ETC. 3-31 
 
 and abstinence from stimulants would counteract all the good 
 ■which would accrue from the use of medicine. It behooves such 
 persons to be cautious as to the selection of their food, and 
 equally so to masticate it thoroughly ; but, unlike the dyspeptic 
 patients, with coated tongues and turbid urine, to whom the 
 former observations respecting diet apply, they need light, 
 nutritious food at shorter intervals than usual, and seldom get 
 on comfortably without a certain amount of sherry, brandy, 
 gin, or whisky. Their appetite is seldom good, and they 
 require beef tea or other light nutriment between their regular 
 meals, and some amount of alcoholic stimulant to rouse their 
 dormant energies, and enable them to digest their heavier 
 meals. Even ale and porter need not always be prohibited. 
 The test of its being required by the system is, that while it is 
 being taken the tongue continues clean, the urine clear, and the 
 skin cool. If any derangement of the secretions should occur, 
 the diet even in these cases must be altered, and the use of the 
 stimulants for a time at least discontinued. Under all circum- 
 stances, Cicero's advice must be remembered, that " tantum 
 cibi et potionis adhibendum, ut reficiantur vires, non oppriman- 
 tur."^ 
 
 Above all things, it is needful for the sufferer from rheumatic 
 gout to take exercise freely and regularly — exercise suited to 
 his strength and condition, but always sufficiently active and 
 sustained to produce a free perspiration. Nothing tends more 
 directly to the perfect oxygenation of the blood, and to the 
 furtherance of those actions on which the ultimate cure must 
 mainly depend. And, as the function of the kidneys is almost 
 always impaired, it is most important to maintain a regular 
 action of the skin, and to guard against damp and chills, and 
 the ill effects of atmospheric vicissitudes, by means of warm 
 clothing. The patient should be clad in flannel or fleecy 
 hosiery, from head to foot, and, should he perspire freely while 
 taking exercise, he should never neglect, on returning home, 
 to change his under-garments, and to make use of friction, by 
 the flesh-brush or coarse towels. 
 
 1 Cicero de Senectute.
 
 332 RHEUMATIC GOUT. 
 
 Sometimes, however, after several attacks, the disease, act- 
 ing upon textures already weakened, appears to be beyond the 
 power of ordinary remedies. In spite of the best directed 
 efforts of the physician, even when aided by the greatest cau- 
 tion on the part of the patient, the stomach performs its func- 
 tions feebly and irregularly ; the appetite remains indifferent ; 
 the food is imperfectly assimilated ; the skin, the" kidneys, and 
 the liver continue sluggish in their action ; effete matters are 
 consequently retained in the system, the joints become more 
 enlarged and distorted, and the general health gives way. 
 Under these circumstances, recourse must be had to the various 
 thermal springs with which Nature has endowed both this 
 country and the Continent, as if for relief of the disease in 
 question. When everything else fails, they not unfrequently 
 afford extraordinary and permanent relief. Whatever the modus 
 opeiandi of the waters, their free use, both internally and 
 externally, exercises a beneficial influence, which is in vain 
 sought from medicine and bathing in other places. The effect 
 produced is at once sedative and tonic. The pain-worn sufferer, 
 irritable and anxious, repairs to the springs, unable to sleep, 
 and troubled with dyspepsia, connected with a sluggish condi- 
 tion of the skin, liver, kidneys, and bowels. After ten days' 
 or a fortnight's trial of their virtues, he begins to find himself 
 less irritable, less anxious, and less wakeful ; he sleeps more 
 soundly, and feels more refreshed by his sleep ; his digestion 
 improves, the whole system is invigorated ; and, after a time, 
 the excretory organs act so much more eflBciently, that it be- 
 comes unnecessary to have recourse to medicines for their 
 relief. Coincidently with this increased freedom in the various 
 channels by which the excretions are carried out of the system, 
 and with the greater purity of blood which consequently 
 ensues, there is observed a decrease in the articular sj'mptoms, 
 which arise, as I have shown, from a vitiated condition of the 
 circulating fluid. There is no fresh accession of pain or inflam- 
 mation, no recurrence of synovial effusion, no increase of 
 thickening about the joints. On the contrary, the enlargement 
 gradually subsides ; and by assistance of the water, applied in
 
 CURATIVE EFFECTS OP THERMAL SPRINGS. 333 
 
 the form of douche, whereby local friction is combined with 
 fomentation, the stiffness disappears, and the patient to a great 
 degree regains his former activity. 
 
 It might be supposed, that the importation of the various 
 waters would render a visit to their source unnecessary. But 
 such is not the case. The natural waters may be taken regu- 
 larly at home, and diligent use may be made of baths contain- 
 ing the same constituents in solution, but the effect is far dif- 
 ferent from that observed during a residence at the springs. 
 The vast importance of the total change of scene, and air, and 
 habits, consequent on a visit to the English or continental 
 watering-places, can hardly be over-estimated : a new stimulus 
 is imparted to the system ; the organic functions receive an 
 impulse which cannot be communicated to them in any other 
 way ; and remedies which have proved unavailing at home, very 
 shortly become active agents for good. Indeed, it is a question 
 whether the benefit derived from a visit to any of the thermal 
 springs is not attributable almost as much to this sort of in- 
 fluence, as to the medicinal action of the waters. 
 
 The only question, therefore, which arises in each particular 
 instance, is as to the place best calculated to promote the well- 
 being of the patient. In this country the waters of Bath, Har- 
 rogate, Buxton, Woodhall, and Droitwich ; abroad those of 
 Aix-la-Chapelle and Bareges ; Wiesbaden, Wildbad, and Baden- 
 Baden : Carlsbad, Teplitz, and Vichy,^ are among the most 
 celebrated and efficient ; but, of course, the physician's selec- 
 tion must be determined by the result of his inquiries into the 
 history of each case. The baths of Harrogate, Aix-la-Chapelle, 
 and Bareges belong to the class of sulphurous waters, and 
 being more stimulant than the other waters alluded to, are 
 sometimes of service in old-standing atonic cases, even when 
 other springs have failed. The two latter are peculiarly 
 adapted for persons of a feeble circulation, who are invigorated 
 by warmth, and suffer greatly from the effects of cold ; while 
 the first-named spring is suited for invalids to whom the dry 
 
 ^ The temperature and composition of most of these waters are given in the 
 Table appended to this chapter. See pp. 347-350.
 
 334 RHEUMATIC GOUT. 
 
 bracinor air which sweeps over the high table-land immediately 
 adjoining Harrogate is likely to prove grateful and beneficial. 
 Judiciously administered, and varied according to the circum- 
 stances of each case, the sulphurous waters in this country and 
 on the Continent have proved a source of renewed health to 
 many a victim to rheumatic gout. The springs of Bath, Wies- 
 baden, Baden-Baden, and Teplitz contain in solution a small 
 quantity of iron, and hence are especially useful whenever 
 there is a deficiency of red globules in the blood. Those of 
 Carlsbad, Avhich also contain iron, prove eminently serviceable 
 in atonic bilious subjects whose livers are inactive, and whose 
 secretions generally are sluggish. The waters of Vichy are 
 strongly alkaline, and are most beneficial in cases characterized 
 by extreme acidity of the stomach and of the excretions ; while 
 those of Buxton and Wildbad, which are strongly impregnated 
 with nitrogen gas, have earned a well-merited reputation in 
 cases marked by the existence of wandering pains, without the 
 concurrence of inflammatory action, — in cases therefore which 
 require alterative waters rather than those of a more stimulat- 
 ing nature. To persons whose skin requires stimulating, and 
 who cannot bear the relaxing effect of the various hot springs, 
 the saline bath of Droitwich is particularly adapted ; to those 
 whose systems are tainted with the venereal poison, or are in- 
 jured by the administration of mercury, and to those again who 
 are suffering from chronic enlargement of the bursae and effusion 
 within the capsular membrane, the iodine and bromine springs 
 of Woodhall, in Lincolnshire, are especially useful ; while those 
 of other places, to which I need not here allude, are equally 
 serviceable in a different class of cases, when administered with 
 due regard to the condition of the patient. But observation has 
 convinced me, that the pallid victim to rheumatic gout, who 
 suffers from cold, and is unable to bear the stimulant effect of 
 the sulphur waters, will usually experience more relief from a 
 month's residence at Bath, than from a much longer sojourn at 
 any other watering-place. 
 
 There is one class of cases, however, which prove extremely 
 intractable, whatever the means adopted for their relief. They
 
 OCCASIONAL CAUSE OF ITS INTRACTABILITY. 335 
 
 are characterized by the unusual pallor of the patient, the dry- 
 ness if not harshness of his skin, the paleness and low specific 
 gravity of the urine, and an utter want of tone in the system. 
 In all cases of rheumatic gout, more especially when occurring 
 in a chronic form, the condition of the urine is of primary 
 importance, as exhibiting at a glance an active or a sluggish 
 state of those organs through whose agency the elimination of 
 the materies morbi is in great measure effected, and without a 
 due action of Avhich it is difficult to conceive that a cure can be 
 permanent. In the obstinateoases just alluded to, this defective 
 condition of the urinary secretion is even more prominent, and 
 is sometimes connected with permanent alteration of the struc- 
 ture of the kidneys, which increases with the progress of the 
 disease until complete degeneration of their secreting apparatus 
 takes place. ^ If the urine be allowed to stand for some hours 
 in a funnel-shaped glass, and the sediment which results be 
 then examined under tlie microscope, scales of glandular epi- 
 thelium will be seen, containing an undue proportion of oil-glob- 
 ules and granular matter, and here and there will sometimes be 
 observed a fibrinous cast of an uriniferous tube, and some small 
 aggregations of amorphous granular matter and half-broken 
 epithelium. Moreover, if the urine be concentrated by evap- 
 oration — sometimes, indeed, without previous concentration — 
 a slight coagulum of albumen will be formed under the influ- 
 ence of heat and nitric acid. After death, the cause of this 
 abnormal condition is apparent : the kidneys are found atro- 
 phied, granular on their surface when their capsule is peeled 
 off, and utterly diseased in their intimate structure. Hence 
 the cause of their defective action ; hence, also, the lingering 
 chronicity of the disease. The only aid we can rationally 
 expect to give a patient whose kidneys are thus diseased, is that 
 afforded by inducing a free action of the skin, liver, and bow- 
 els, and by regulating the amount and nature of the food. By 
 
 1 This complication is of frequent occurrence in true Gout, and appears to 
 be dependent on, or intimately connected with, the causes which produce the 
 original disease: in Rheumatic Gout, on the contrary, it is of rare occurrence, 
 and seems to be an accidental coincidence, in no way connected with the mor- 
 bid changes in which the primary disease takes its origin.
 
 336 RHEUMATIC GOUT. 
 
 relieving the diseased organs of part of their work ; by stimu- 
 lating the healthy secreting apparatus to take on vicarious 
 action, and so to assist in the elimination of the poison, as also 
 by strict attention to diet and regimen, we may do much 
 toward warding oft' the final catastrophe. Though we cannot 
 effect a cure of the disease, we may render our patient's suffer- 
 ings endurable, and enable him to pass the remainder of his 
 life in comparative comfort to himself and family. 
 
 Hitherto I have made only slight allusion to the various 
 complications which render this complaint peculiarly formi- 
 dable, and call for immediate relief. Nor do I intend to enter 
 at any length into the discussion of symptoms which, though 
 sometimes arising in the course of this disease, are yet of fre- 
 quent occurrence under other circumstances, and do not demand 
 any specific treatment. Inflammation of the brain has been 
 met Avith, though rarely, and has occurred almost invariably 
 coincidently with the subsidence or sudden retrocession of the 
 articular symptoms.' Moreover, in almost every case on record, 
 it has supervened after the disease has been limited for some 
 time to one or two joints, and its attacks have been confined 
 to persons in an unhealthy cachectic condition, who have been 
 exhausted and rendered irritable by the long continuance of 
 the disease. Its symptoms have seldom exhibited the same 
 activity as those which ordinarily accompany inflammation of 
 the brain ; there' has seldom been much inflammatory fever or 
 violent delirium, but the disease has gone on rapidly to a 
 fatal termination, w"ith headache, incoherence, strabismus, 
 paralysis, and symptoms of pressure on the nervous centers. 
 Instances in point may be found recorded in Sir Benjamin 
 Brodie's work "On Disease of the Joints,"^ in Dr. Macleod's 
 chapter on " Capsular Rheumatism,"^ and in several of the 
 medical periodicals ; but as all the cases are devoid of interest, 
 
 1 Since the publication of the first edition of this work, I have seen reason 
 to doubt whether inflammation of the brain, or pleurisy, is ever set up as a 
 consequence of rheumatic gout. I have never met with a case in point, and, 
 after carefully reconsidering the recorded cases, ray impression is that they 
 were all instances of true gout or true rheumatism. 
 
 * Ed. 4, p. 51. 3 Qn "Rheumatism,' p. 118.
 
 AFFECTIONS OF THE EAR. 337 
 
 save only in so far as they serve to illustrate the reality and 
 danger of such an occurrence, I shall content myself by refer- 
 ring to the fact of their having been recorded, and impressing 
 upon all those who may have charge of patients laboring under 
 this disease, the necessity of taking active and immediate 
 measures should headache, vertigo, somnolency, impaired mem- 
 ory, or any other symptoms appear to indicate commencing 
 mischief within the cranium. Should such symptoms be accom- 
 panied, as they usually are, by the subsidence or disappearance 
 of articular swelling, it may be worthy of consideration, whether 
 by the application of mustard poultices and blisters, it may not 
 be possible again to attract the morbific agent to the joints, 
 and so to avert the fatal consequences which must follow the 
 concentration of its whole force upon the brain. 
 
 Pleurisy is a more common, and practically, therefore, a 
 more important complication.^ In some instances, where the 
 system is low and susceptible of irritation, pleuritic inflamma- 
 tion is readily excited, and often occurs without any manifest 
 decrease in the articular symptoms. Frequently, in such cases, 
 the morbid action is limited in extent, and may be easily 
 checked by ap])ropriate treatment. But in other cases it arises 
 coincidently with, and probably in consequence of the sudden 
 subsidence of the articular swelling ; and then if the system be 
 depressed, it is rapid in its progress, pus-generating in its 
 character, and little under the control of medicine. In such 
 instances the whole virulence of the poison appears to be con- 
 centrated upon the inflamed membrane, and the patient sinks, 
 in part from the shock, and in part exhausted by the irritation 
 of the disease, and by the oppression to the breathing which 
 results from an accumulation of pus and serum in the pleural 
 cavity. 
 
 Deafness is a complication which unfortunately arises in a large 
 proportion of patients who suff"er from rheumatic gout, and proves 
 at once distressing to the sufferer, and extremely obstinate in its 
 continuance. The small bones of the ear become involved in the 
 changes which have been already traced in connection with the 
 
 1 See Note oq p. 336 of this Treatise.
 
 338 RHEUMATIC GOUT. 
 
 articulations of the extremities, and distortion and loss of mo- 
 tion result. Not unfrequently the action of the tensor tympani 
 appears to be interfered with early in the attack, producing 
 partial deafness ; and as soon as distortion of the bones has 
 proceeded beyond a certain point, and rigidity of their articu- 
 lations has occurred, the muscles become utterly incapable of 
 moving them, and complete deafness ensues. 
 
 The plan of treatment commonly pursued in these cases is 
 the application of blisters and irritating ointments behind 
 the ears, followed by mercurial inunction, and the internal 
 administration of mercurials and alkalies ; but having known 
 this method fairly carried out by experienced aurists in a large 
 number of cases, almost uniformly without success, I cannot 
 but doubt whether it exercises the slightest curative influence. 
 My own observation would rather lead me to recommend the 
 administration of tonics, cod-liver oil, and remedies which 
 experience has proved to be productive of relief to the local 
 effects of the disease in other parts of the body, and at the 
 same time to have recourse locally to the absorbent influence 
 of the biniodide of mercury ointment rubbed in behind the 
 ears. 
 
 Inflammation of the eye is another complication of consid- 
 erable importance. It occurred in 11 out of the 130 cases of 
 rheumatic gout which were admitted into the hospital during 
 the time I held the office of Medical Registrar, and the eye has 
 suffered more or less severely in 14 out of 198 cases which have 
 fallen under my own care at the hospital.^ In private prac- 
 tice, too, within the last few years, several gentlemen have 
 consulted me for the same train of symptoms. Therefore, 
 
 ^ Since the above paragraj)hs were published in the first edition of this work, 
 I have seen reason to doubt whether tiie affection is so common as these figures 
 would appear to indicate, and whether many, if not all, of the cases in which this 
 complication arose may not have been cases of obscure gout or of gonorrhoeal 
 rheumatism. This at least is certain, that since my attention has been specially 
 directed to this question, I have been enabled to trace a gouty or venereal 
 taint in every case in which the eye has been inflamed in connection with 
 presumed rheumatic gout. Nevertheless, I have not as yet obtained sufficient 
 evidence to justify a positive opinion on the subject, and therefore have not 
 thought it right to interfere with the text.
 
 AFFECTIONS OF THE EYE. 839 
 
 although inflammation of the eye is comparatively rare in 
 rheumatic gout, it is sufficiently common to demand our serious 
 attention. 
 
 Affections of the eye, in connection with rheumatic gout, are 
 usually seen in those who are thoroughly out of health or ex- 
 hausted by repeated attacks of the disease. The inflammatory 
 process is not confined to any particular part or texture of the 
 eye, but often attacks, either together or in succession, the 
 various coats of which the eye is composed. The conjunctiva, 
 the sclerotic, the choroid, and the iris are all sometimes impli- 
 cated before the disease is arrested ; but more commonly, if 
 the patient is under medical treatment, the choroid and the 
 iris escape altogether. Very generally the inflammation com- 
 mences in the sclerotic and spreads to the conjunctiva, and 
 though not very violent, continues, in spite of treatment, for 
 several days. Even when all symptoms of inflammation have 
 been subdued, and the eye has regained its natural appearance, 
 the morbid action is prone to recur without any manifest exter- 
 nal cause. Rarely," however, unless grossly neglected, does 
 the inflammation leave permanent ill effects ; nor does it require 
 the same activity in its general treatment, nor the same amount 
 of topical applications which would be necessary for its relief 
 in ordinary cases. In some instances it may be deemed expe- 
 dient to give calomel and opium, and to apply a blister behind 
 the ear, or a few leeches to the temples, but more commonly 
 opiate fomentations to the eyes, with cold applications to the 
 temples, and derivatives, such as mustard poultices or mustard 
 baths, to the feet; and internally, a brisk purgative, followed 
 by an alkaline mixture containing colchicum, will be sufficient 
 to effect our purpose. If the patient be very low, calomel 
 given so as to produce ptyalism aggravates rather than miti- 
 gates the disease, and in such cases the iodide of potassium 
 and cinchona maybe employed beneficially in combination with 
 small doses of the liquor Ilydrargyri Bichloridi. Indeed, in 
 this, as in all similar instances, the symptoms must be combated 
 on general principles, due regard being had to the nature of 
 the disease in connection with which they have primarily 
 arisen.
 
 340 RHEUMATIC GOUT. 
 
 The following cases will serve to illustrate the treatment of 
 some of the more obstinate forms of Rheumatic Gout. 
 
 Case I. — On the 15th of November, 1855, I was asked by 
 Mr. Nussej, of Cleveland Row, to meet him in consultation on 
 
 the case of Miss , a young lady, set. 23, who for three 
 
 years had been thoroughly crippled by rheumatic gout. One 
 of her aunts had suffered from this complaint, but she had never 
 before experienced any rheumatic symptoms. The attack had 
 come on slowly and insidiously while she was apparently in the 
 enjoyment of good health. Joint after joint became enlarged 
 and painful, until at length there was hardly a joint in her 
 body which was not frightfully distorted. Her spine was stiff, 
 and could not be bent without much difficulty. Her neck was 
 stiff, as were also the shoulders, so that she was unable to raise 
 her arms to her head ; the elbows, wrists, and both knees and 
 ankles were much enlarged ; the hands were distorted, and some 
 stiffness existed in the hips. She had been under medical 
 treatment throughout, and had consulted several physicians, 
 who had ordered Colchicum, Alkalies, Guaiacum, Iodide of 
 Potassium, Sarsaparilla, Cod-liver Oil, Quinine, and many 
 other remedies ; and for two successive summers she had gone 
 to the German baths in the vain hope of obtaining relief. 
 
 When I first saw her she was a perfect cripple ; she could 
 not walk, and was unable to get from her bed-room to the 
 drawing-room without going upon '• all-fours." She could not 
 rise from her chair Avithout a long and painful struggle. The 
 skin was acting freely, almost too readily, on exertion, and was 
 frequently covered with a cold, clammy perspiration. Tongue 
 coated ; bowels rather costive ; urine very scanty, and loaded 
 with lithates, sp. gr. 1019. Catamenia regular, but too pro- 
 fuse. She had a fair appetite, and never suffered from indi- 
 gestion, but, as is usual in such cases, she was becoming " low 
 spirited." Heat oppressed her, and she was always in better 
 health in cold than in hot weather. A pill containing two 
 grains and a half of the acetous extract of Colchicum, a grain 
 of Ipecacuanha, and enough of the Ext. Aloes Aquosum to 
 regulate the bowels, was ordered to be taken every night, and
 
 TREATMENT. 841 
 
 another pill containing two grains of the Pilula Hydrargyri 
 was administered as occasion required. A draught containing 
 Potassae Acetatis, jss, Potassse Carb., 9i, Potassii lodidi, gr. 
 iv, Ext. Taraxici, .5ss, and Tr. Cinchonre co., .5Jss, was ordered 
 to be taken three times a day with Olei Morrhute, oSS. Gin 
 or whisky and water was the beverage prescribed for dinner, 
 and lemonade was also permitted, if she felt thirsty during the 
 day. A shower bath of cold water, followed by prolonged and 
 active friction down the spine, was ordered to be taken every 
 morning, and an absorbent ointment, frequently repeated fric- 
 tion, and various mechanical movements were employed to get 
 rid of the stiffness and chronic enlargement of the joints. Slow 
 mastication and other accessories of good digestion were also 
 specially insisted on. 
 
 In the course of a month some improvement began to mani- 
 fest itself, and though from time to time some slight alteration 
 was made in the medicine, the general plan of treatment 
 remained the same. The chief alteration which was made 
 consisted in the substitution of a strong infusion of the Frax- 
 inus excelsior for the Tincture of Cinchona. Before the end 
 of three months she was able to take a walk out of doors for 
 half an hour, and after a steady perseverance of five months 
 her general health had greatly improved ; the swellings of the 
 joints had almost wholly disappeared ; the stiffness had greatly 
 decreased, and she was on the high road to perfect recovery. 
 I have not seen her for several months, but I hear from Mr. 
 Nussey that she has almost entirely recovered her usual health 
 and strength, though some of the joints remain permanently 
 distorted. 
 
 Case II. — .Jane Hardy, a married woman, ?et. 30, was ad- 
 mitted under my care at St. George's Hospital on the 16th of 
 June, 1855, suffering from rheumatic gout of two years' dura- 
 tion. She had been under treatment above eighteen months, 
 and had taken many warm baths, but was not aware what rem-
 
 342 RHEUMATIC GOUT. 
 
 edies had been employed internally. "When I first saw her, she 
 was thin, pale, and cachectic in appearance ; her feet, ankles, 
 both wrists, and several of the finger joints were enlarged, 
 swollen, and occasionally painful ; the skin was dry, and un- 
 perspiring ; indeed, if her own account was to be trusted, even 
 a hot bath did not cause the slightest perspiration : tongue 
 somewhat coated. Bowels regular. Catamenia regular, but 
 scanty. Urine formerly turbid, but now usually clear, and 
 rather scanty, sp. gr. 1020 ; appetite tolerably good. Is rest- 
 less at night, and feels very weak and low spirited. 
 
 I advised her to abstain from tea and malt liquor : to take 
 gin or whisky and water at dinner ; to have recourse to a vapor 
 bath twice a week, and to employ a cold douche daily for her 
 feet and ankles. An absorbent ointment was ordered for the 
 joints, and the following medicines were also prescribed : 
 
 I^. Potassii lodidi, gr. v ; 
 Liq. Potassae, tt^xlv ; 
 Tr. Guaiaci Ammoniatae, 5J j 
 Baust. Cinchonaj, S^ss, ter die. 
 
 On the 14th of July, she was very little, if at all, improved. 
 The vapor bath gave rise to excessive heat, fullness about the 
 head, and excitement, but did not make her perspire, and the 
 skin remained just as dry as before. The urine was more 
 abundant and clear, but the other symptoms remained the same. 
 The following addition was therefore made to the medicine, 
 which was ordered to be taken soon after meals, viz.: 
 
 Liquoris Potassae Arsenitis, it^viij ; 
 
 and a cold shower bath was substituted for the vapor bath. 
 
 From this time her improvement was very marked, and 
 steadily progressive. The skin began to perspire within three 
 days after the first dose of arsenic had been taken, and by the 
 10th of August, the complexion had become clearer, the pains 
 less constant and severe ; the sp. gr. of the urine had in- 
 creased to 1026, and she felt stronger and better in every 
 respect. 
 
 From the 29th of September until the 27th of October, the
 
 TREATMENT. 343 
 
 arsenic was omitted by way of precaution, but at that date, as 
 the skin's action was becoming sluggish, the use of the arseni- 
 cal solution was resumed, and continued until the 24th of No- 
 vember, when I determined once again to try whether its dis- 
 use would lead to inactivity of the skin. At this time the pain 
 and swelling of the joints of the upper extremities had wholly 
 disappeared ; the knees were no longer swollen, and the feet 
 and ankles alone remained painful. She declared that her 
 general health was better than it had been since the commence- 
 ment of the attack, and that were it not for the pain in the 
 feet, especially after walking, she should consider herself quite 
 well. 
 
 The discontinuance of the arsenic had a marked effect in 
 diminishing the amount of perspiration, but as the gkin still 
 continued moist, I did not deem it necessary to have recourse 
 to it again at present. 
 
 On the 5th of January she had a slight feverish attack ac- 
 companied by relaxation of the bowels, and as it was probably 
 attributable to the long-continued use of the ammoniated 
 Tincture of Guaiacum, the former draught was omitted, and 
 the following prescribed : 
 
 ^.. Potassii lodidi, gr. v; 
 Liquoris Potassae, 5ss; 
 Potassae Acetatis, 5ss ; 
 Ext. Sarzae, ^ss; 
 Haustus Cinchonae, §jss, ter die. 
 
 On the 19th of January, as the skin action was again be- 
 coming sluggish, the arsenical solution was added to the 
 draught, and was persisted in until the 1st of March, when it 
 was finally discontinued, the skin having acted freely ever 
 since. 
 
 On the 26th of April, she was so well that it was no longer 
 necessary for her to continue taking medicine, and I advised 
 her going into the country for change of air, with the view of 
 thoroughly re-establishing her health.
 
 344 RHEUMATIC GOUT. 
 
 Case III.— On the 18th of October, 1853, I was consulted 
 by Miss W , aet. 21, who, at the recommendation of Mr. Ne- 
 ville, of Esher, had been brought to London to be placed under 
 my care. She had been suffering above a year and a half from 
 rheumatic gout, which, though at first confined to the wrist and 
 the small joints of the fingers, had gradually extended the range 
 of its attacks, until few, if any, of the joints had escaped. 
 
 When she first applied to me she was a perfect cripple, and 
 unable to raise her hand to her head ; the shoulders, elbows, 
 and wrists were swollen, stiff, and painful ; the small joints of 
 the fingers were distorted, the knees and ankles were painful, 
 and she suffered from pain and stiffness of the neck. The 
 symptoms first manifested themselves at a time when she was 
 apparently in good health ; but with the progress of the dis- 
 ease the general health had failed, and she had become thin, 
 weak, dyspeptic, and low spirited. Her circulation was very 
 languid ; the extremities were almost always cold ; the pulse 
 74, feeble ; the tongue white and coated ; the bowels regular 
 in action, but the motions often pale or else dark colored and 
 offensive : the monthly periods regular ; the urine scanty, 
 turbid, acid, sp. gr. 1018 ; the skin usually damp, with a cold 
 clammy perspiration. 
 
 She had taken large quantities of iodide of potassium, col- 
 chicum, and other remedies, without the slightest relief, and 
 had had a succession of hot baths with the same result. The 
 manifest want of tone in the system led me to recommend a 
 tonic and alterative plan of treatment. A cold shower bath 
 was ordered to be taken daily, and to be followed by active 
 friction down the spine ; an absorbent ointment was ordered 
 for the joints, and the following medicines were prescribed : 
 
 ^. Ilydrargvri Chloridi, gr, xij ; 
 
 Extract! Aloes Aquosi, 
 
 Extracti Colcliici Acet., aa 3j. 
 M. ft. Pilulfe duodecim quarura siimatur una onini alterou noctc. 
 
 Liquoris Potass.c, §iss; 
 
 Tinctur.T Guaiaci Ammon., §ij ; 
 
 Extracti Sarzaj, ^iss ; 
 
 Tinctura^ Ciiichoiiae co., §iij. 
 M, ft. mistura, cujus sumatur cochlearium unum magnum e cyatho aquae 
 vinario ter die.
 
 TREATxMENT. 345 
 
 Malt liquor and wine were interdicted ; a light but generous 
 diet enjoined, and gin or whisky and water recommended as a 
 beverage at dinner. 
 
 After eight weeks' steady perseverance with this treatment, 
 very decided amendment w^as manifest. The general health 
 was beginning to improve ; she suffered far less from dyspepsia 
 and depression of spirits ; her complexion was clearer ; the 
 tongue raoister and less coated ; the urine more abundant, 
 though still turbid ; the bowels were regular, and the motions 
 of a more healthy character ; the joints were much less swollen, 
 and, with the exception of the right wrist, were no longer 
 painful. 
 
 On the 9th of December, 1853, fifteen grains of the Pil. 
 Rhei c. were substituted for the calomel, and the pills and 
 medicine were continued as before. 
 
 From this date until the 21st of June, 1854, this plan of 
 treatment, with slight modifications, was steadily persevered in. 
 By that time she was in good health and spirits, could take a 
 long walk without inconvenience, and could dress and otherwise 
 assist herself, though some stiffness of the shoulders still 
 remained, and the wrists occasionally evinced symptoms of 
 irritation. The urine was now abundant and clear ; the bowels 
 regular, the motions healthy. The pulse, however, remained 
 weak, and she was still somewhat thin ; so I ordered her to take, 
 twice a day, with half an ounce of cod-liver oil, a draught con- 
 taining Potassge Bicarb., 9j ; Ammonise Sesquicarb., gr. v ; 
 Tincturae Quinae, 3j. At the same time, active friction, with 
 stimulant embrocations and absorbent ointments, were pre- 
 scribed for the shoulders. 
 
 From this time onward her progress was steady and satis- 
 factory in every respect, and so well did she feel, that ere long 
 she gave up physic, and went on a visit to a married sister at 
 Oporto. 
 
 Case IV. — William Collins, set. 39, a printer by trade, was 
 admitted a patient under my care at St. George's Hospital, on 
 23
 
 346 RHEUMATIC GODT. 
 
 the 4th of March, 1856. At the age of 24 he was profusely 
 salivated for the cure of syphilis, and had ever since suffered 
 more or less from rheumatic gout, principally affecting the 
 small joints of the hands, the wrists, and elbows. The disease 
 was at first confined to the joints of the fore and middle fingers 
 of the right hand, but had gradually extended to other parts, 
 until, when he came under my care, almost every finger was 
 enlarged, stiff, and incapable of being bent. He said that he 
 did not experience much acute pain, but suffered constantly 
 from aching stiffness of the joints, was incapable of and 
 thoroughly indisposed for work, and felt low, irritable, and 
 restless. He was thin, and cachectic in appearance ; his tongue 
 was almost clean ; bowels reported regular ; urine either pale 
 or else scanty and turbid ; appetite indifferent. 
 
 Steaming and friction, with absorbent and stimulating appli- 
 cations, were ordered for the joints, and the following medi- 
 cines prescribed : 
 
 ^. Extract! Colchici Acet., gr. ij, omni nocte. 
 
 Potassii lodidi, gr. vj ; 
 
 Potassse Bicarbonatis, 5ss ; 
 
 Potassse Acetatis, 3j ; 
 
 Olei Morrhuae, ^iv ; 
 
 Tnfusi Calutnba", j, ter die. 
 
 By the 1st of April a sensible improvement had taken place. 
 The joints were more flexible ; the urine was more abundant 
 and clear ; there was less aching in the joints ; and he felt in 
 better spirits. 
 
 The medicines were therefore continued. 
 By the 22d of April more decided progress had been made. 
 He no longer experienced any pain ; the joints were decidedly 
 smaller and more flexible ; the appetite was good ; and the 
 water abundant and quite clear. He was still pale ; and so the 
 following draught was ordered in lieu of that he had hitherto 
 taken : 
 
 ^. Potassii lodidi, ar. vj ; 
 Syrupi Ferri lodidi, 5j j 
 Olei Monhute, 3'v ; 
 Infusi Ciilumb;e, 3^'U) t^i" "i'^' 
 The pill was repeated as before.
 
 TEMPERATURE, ETC., OF THERMAL SPRINGS. 
 
 347 
 
 Under this treatment the general health improved, the joints 
 decreased in size and became more flexible, and he was enabled 
 to resume his occupation as a printer. On the 20th of May he 
 went into the country, and from that time I lost sight of him. 
 
 Table 
 
 Exhibiting the Temperature and Constituents of various Thermal Springs. 
 
 BUXTON WATER. 
 
 Analysis by Dr. Lyon Play fair. 
 
 Water clear, sparkling, inodorous. 
 
 Temperature — 82° Fahrenheit ; sp. gr. 
 
 1-0003. 
 
 Solid contents of a Gallon : 
 
 grs. 
 Silica . . . 0-666 
 
 Oxide of Iron and Alumina . 0-240 
 Carbonate of Lime . . 7-773 
 
 Sulphate of Lime . . 2-323 
 
 Carbonate of Magnesia . 4-543 
 Chloride of Magnesium . 0-114 
 " Sodium . . 2-420 
 
 " Potassium . 2-500 
 
 Fluorine 
 
 (as Fluoride of Calcium) trace 
 Phosphoric Acid 
 
 (as Phosphate of Lime) trace 
 
 20 579 
 
 Gaseous contents according to Volume: 
 
 Carbonic Acid . . 1-167 
 
 Nitrogen . . . 98-833 
 
 Oxygen . . . trace 
 
 100-000 
 
 At the moment of issue the water con- 
 tains 206 cubic inches of Nitrogen 
 per gallon. 
 
 WOOD HALL SPA. 
 Wood Hall, near Horncastle, Lincoln- 
 shire. 
 Analysis by Mr, West, of Leeds. 
 Temperature — 55° Fahrenheit ; sp. gr. 
 
 1016. 
 
 
 Solid contents of a Gallon : 
 
 
 
 grs. 
 
 Chloride of Sodium 
 
 1517-00 
 
 " Calcium 
 
 27-00 
 
 " Magnesium 
 
 11-00 
 
 Bicarbonate of Soda 
 
 6-00 
 
 Sulphate of Soda 
 
 2-00 
 
 Bromine 
 
 8-48 
 
 Iodine 
 
 -50 
 
 
 1571-98 
 
 Gaseous contents : 
 
 
 Nitrogen . cub. in 
 
 :h. 20 
 
 Carbonic Acid 
 
 . 18 
 
 Carburetted Hydrogen 
 
 4-50 
 
 Sulphuretted Hydrogen 
 
 trace 
 
 HARROGATE WATERS. 
 
 Analysis by Professor Hofmann. 
 
 Old Sulphur Well. 
 
 Temperature — 48-2° Fahrenheit; sp. gr. 
 1 01113.
 
 348 
 
 TEMPERATURE, ETC., OF THERMAL SPRINGS. 
 
 Grains of Saline constitiic 
 
 its ma tfullon: 
 
 Sulphate of Lime . 
 
 •182 
 
 Carbonate of Lime 
 
 . 12-365 
 
 Chloride of Calcium 
 
 . 81-735 
 
 '• Macfnesium 
 
 . 55-693 
 
 " Potassium 
 
 . 64-701 
 
 " Sodium 
 
 . 866 180 
 
 Sulphide of Sodium 
 
 . 15-479 
 
 Silica . 
 
 •246 
 
 
 1096-580 
 
 Fluoride of Calcium, Bromide of So- 
 dium, Iodide of Sodium, Ammonia, 
 Carbonateof Iron, andorg anic mat- 
 ter, of each a trace. 
 
 Sulphuretted Hydrogen Gas, 26-9 cu- 
 bic inches. 
 
 DROITWICH SALINE BATH. 
 Analysis by Mr. Herapath. 
 Solid contents of a Gallon : 
 
 Chloride of Sodium 
 
 Magnesium 
 
 Sulphate of Lime 
 " Alumina 
 
 <' Soda 
 
 Iodide of Sodium 
 
 grs. 
 
 21,761-872 
 
 2-560 
 
 91-120 
 
 14-400 
 
 342-720 
 
 •208 
 
 22,212-880 
 
 BATH WATERS. 
 
 Analyzed hy Merck c^- Galloway, in 1848. 
 
 King's Bath Spring. 
 
 Temperature— llo° Fahrenheit; 
 
 sp. gr. 1-0025. 
 
 Contents of an Imperial Gallon : 
 
 Carb. of Lime . grs. . 8-820 
 
 " Magnesia . . -329 
 
 " Iron . . . 1-071 
 
 Sulphate of Lime . . 80052 
 
 " Potassa . . 4-642 
 
 " Soda . . 19-229 
 
 Chloride of Magnesium . 14-581 
 
 " Sodium . .12-642 
 
 Silicic Acid . . . 2-382 
 
 144-018 
 
 BAREGES WATER. 
 
 Temperature, about 120° Fahr. 
 
 Contains : 
 
 Sulphide of Sodium. 
 
 Carbonate of Soda. 
 
 Sulphate of Soda. 
 
 Chloride of Sodium. 
 
 Nitrogen. 
 
 Free Sulphuretted Hydrogen. 
 
 Animal Matter. 
 
 Carbonic Acid, 26-45 cubic inches. 
 
 AIX-LA-CHAPELLE. 
 
 Analysis of the Kaiserkelle 
 
 (^Source de VEmpereur) by Liebig. 
 
 Temperature — 131° Fahrenheit; 
 sp. gr. 1-0034. 
 
 Contains in a Pint, of 16 oz. : 
 Chloride of Sodium grs 
 Carbonate of Soda 
 Sulphate of Soda 
 Sulphate of Potassa 
 Carbonate of Lime 
 
 " Magnesia 
 
 " Iron 
 
 " Strontia 
 
 " Lithia 
 
 Bromide of Sodium 
 Iodide of Sodium 
 Sulphuret of Sodium 
 Silica 
 Organic Matter . 
 
 20-270 
 
 4-995 
 
 2171 
 
 1-186 
 
 1-217 
 
 •395 
 
 •073 
 
 •001 
 
 •000 
 
 •027 
 
 -004 
 
 -072 
 
 •507 
 
 •577 
 
 31-497 
 
 Gaseous contents according to Volume 
 Absorbed in the Water : 
 
 Nitrogen 
 
 Carbonic Acid 
 
 Bihidroguret of Carbon 
 
 Sulphuretted Hydrogen 
 
 Oxygen 
 Free and rising in the water : 
 
 Nitrogen 
 
 Carbonic Acid 
 
 Bihidroguret of Carbon 
 
 Sulphuretted Hydrogen 
 
 Oxygen 
 
 9-00 
 
 89-40 
 
 •37 
 
 •00 
 
 1.23 
 
 66-98 
 
 30-89 
 
 •182 
 
 -3' 
 
 •00
 
 TEMPERATURE, ETC., OF THERMAL SPRINGS. 
 
 349 
 
 WIESBADEN WATER. 
 Analysis by Fresenius. 
 Temperature of Kochbruanen 
 
 158° Fahrenheit. 
 Contains in a Pint: 
 Chloride of Sodium grs. 
 " Potassium 
 
 " Lithium 
 
 " Ammonium 
 
 " Calcium . 
 
 " Magnesium 
 
 Sulphate of Lime 
 Carbonate of Lime . 
 " Magnesia 
 
 " Protoxide 
 
 of Iron 
 
 Water, 
 
 52-497 
 1-119 
 •001 
 •128 
 •617 
 •566 
 •692 
 •210 
 -079 
 
 -043 
 
 55-952 
 
 With traces of Iodine, Bromine, 
 Arsenic, Alumina, Strontia, Cop- 
 per, Manganese, Bar_) ta, Silica, and 
 organic matter, bringing the solid 
 contents of a Pint up to 63-457 grs. 
 
 Carbonic Acid free and com- 
 bined with Carbonates . 3-903 
 
 Nitrogen . . . . -015 
 
 IBADEN-BADEN WATER. 
 
 Analysis by Kastner. 
 
 
 Temperature of Ursprung, 
 
 about 
 
 120° Fahrenheit. 
 
 
 A Pint contains : 
 
 
 Chloride of Sodium grs. 
 
 . 17-500 
 
 " Calcium . 
 
 . 1-500 
 
 " Manganese 
 
 -500 
 
 Sulphate of Lime 
 
 . 2-750 
 
 Carbonate of Iron 
 
 •111 
 
 
 22-361 
 
 Free Carbonic Acid, '5 cubic inches. 
 
 TEPLITZ WATER. 
 Analysis by Ambrozzi. 
 Temperature — 114° Fahrenheit. 
 A Pint contains: 
 
 Sulphate of Soda grs. . 1-696 
 
 Chloride of Sodium . . -776 
 Carbonate or Soda . 12-240 
 
 Carbonate of Lime 
 BiHca . 
 Extractive . 
 Carbonate of Iron 
 
 -340 
 -420 
 •100 
 -036 
 
 15-608 
 
 Free Carbonic Acid, 2-4 cubic inches. 
 
 CARLSBAD WATER. 
 Analysis of the Sprudel, by Berzelius. 
 
 Temperature — 167° Fahrenheit. 
 Sixteen Ounces contain: 
 
 Chloride of Sodium grs. . 7-975 
 
 Sulphate of Soda . . 19-869 
 
 Carbonate of Soda . . 9-695 
 
 " Lime . . 10050 
 
 " Magnesia . 1-370 
 
 " Iron . . -028 
 
 Silica 577 
 
 43-564 
 
 With traces of Manganese, Strontia, 
 Alumina. 
 
 Free Carb. Acid, 11*8 cubic inches. 
 
 WILDBAD WATER. 
 Analysis by Siywerth. 
 Temperature— ^ii° Fahrenheit. 
 Sixteen Ounces contain : 
 Chloride of Sodium grs. 
 Sulphate of Soda 
 Carbonate of Soda 
 " Lime 
 
 " Magnesia 
 
 Sulphate of Potash 
 Silica 
 Oxide of Iron 
 
 " Manganese . 
 
 1-820 
 ■400 
 -530 
 -340 
 -070 
 -020 
 •390 
 •020 
 •030 
 
 3-610 
 
 Gaseojfs contents according to Volume: 
 Carbonic Acid . . . 2-00 
 0-xygen .... 650 
 Nitrogen .... 91-50 
 
 10000
 
 360 
 
 TEMPERATURE, ETC., OF THERMAL SPRINGS. 
 
 VICHY WATEPvS. 
 
 ANALYSIS BY MONS. BOUQUET. 
 
 Contents of a Litre of Water expressed in grammes. 
 
 Constituents of the Vichy Waters. 
 
 Grande 
 Grille. 
 
 Hopital. 
 
 C61estins. 
 
 Hauterive. 
 
 Des 
 Dames. 
 
 Carbonic Acid 
 
 Bicarb, of Soda 
 
 " of Potass ' 
 
 " of Magnesia .... 
 
 " of Strontia .... 
 
 " of Lime 
 
 " of Protoxide of Iron . 
 Bicarb, of Protoxide of Mungauese 
 
 Sulphate of Soda 
 
 Phosphate of Soda .... 
 Arseniate of Soda .... 
 
 Borate of Soda 
 
 Chloride of Sodium .... 
 
 Silica 
 
 Organic Matter, Bituminous . 
 
 Temperature . . . i 
 
 0-908 
 4 883 
 0-352 
 0-303 
 0-003 
 0-434 
 0-004 
 
 A trace 
 0-291 
 0-130 
 0-002 
 
 A trace 
 0-534 
 0070 
 
 A trace 
 
 1-067 
 5-029 
 0-440 
 0-200 
 0-005 
 0-570 
 0-004 
 
 A trace 
 291 
 0-046 
 0-002 
 
 A trace 
 0-518 
 0050 
 
 A trace 
 
 1-299 
 4 101 
 0-231 
 554 
 0-005 
 0-6tj9 
 0004 
 
 A trace 
 0-314 
 
 A trace 
 0003 
 
 A trace 
 0-550 
 0-065 
 
 A trace 
 
 2 183 
 4-687 
 0189 
 0-501 
 0-003 
 0432 
 0-017 
 
 A trace 
 0-291 
 0-046 
 0-002 
 
 A trace 
 0-534 
 0-071 
 
 A trace 
 
 1-908 
 4016 
 0-189 
 0-425 
 0-003 
 0-604 
 0026 
 
 A trace 
 0-250 
 
 A trace 
 0-003 
 
 A trace 
 0-355 
 0-032 
 
 A trace 
 
 7 914 
 
 8-222 
 
 7-865 
 
 8 946 
 
 7-811 
 
 105° 
 Fah, 
 
 87° 
 Fah. 
 
 55° 
 Fah. 
 
 58 to 61° 
 Fah. 
 
 cold.
 
 353 
 
 ' ic disorder, and 
 
 ''ormer case 
 
 '~ey fre- 
 
 CHAPTER XII. 
 
 ON CHRONIC RHEUMATISM. 
 
 When describing the symptoms of acute rheumatism, I re- 
 marked on the difference of the structures affected in different 
 cases, and pointed out the reasons which induced me to chissify 
 all the varieties under one comprehensive title. I stated that, 
 although in some instances one texture or one part of the body 
 may be principally if not exclusively affected, yet that much 
 more frequently the different forms of the disease coexist to 
 some extent in the same individual, or at least pass rapidly the 
 one into the other, thus not only asserting the identity of their 
 origin, but rendering a classification, founded simply on ana- 
 tomical peculiarities, inconsistent with the pathological phenom- 
 ena. The same reasons may be urged with equal propriety 
 against the distinctions which have been drawn between the 
 varieties of the disease as they are met with in a chronic form. 
 In some instances the fibrous structures about the joints, in 
 some the capsular membrane lining the joints, in some the 
 fibrous envelopes of the nerves, and in others the muscles with 
 the aponeurotic sheaths, the fascite and tendons, or the perios- 
 teum in various parts of the body, may be more conspicuously 
 affected ; but occasionally one variety lapses into another, and 
 a fibrous rheumatism may thus, after a time, be complicated or 
 replaced by synovial symptoms, and may ultimately terminate 
 in sciatica, or some other form of neuralgic pain, or in rheu- 
 matism affecting the muscles only. 
 
 Whether, then, in an acute or chronic form, the disease is 
 always one and the same, acknowledging the same origin, though 
 varying in its type according to the age and constitution of the 
 patient, the quantity of the poison present in the system, and a
 
 352 CHRONIC RHEUMATISM. 
 
 variety of other modifying circumstances.^ Whatever its pre- 
 cise character, however, the acute may pass into the chronic 
 form, and the chronic may light up into an active state, and 
 present the symptoms of the acute disorder. These are facts of 
 every-day experience, and receive constant illustration in the 
 wards of every large hospital. But, according as the disease 
 is acute or chronic, a remarkable difference is usually observed 
 in the parts principally affected. Thus, an acute attack is 
 often ushered in by wandering pains, which are chiefly if not 
 wholly confined to the muscular structures ; but no sooner are 
 the acute symptoms developed, than the muscular pains subside, 
 and the joints are chiefly if not solely affected. So, again, 
 when all acute symptoms have disappeared, not only does there 
 remain a stiffness or a dull aching pain in the joints, but the 
 muscles in various parts of the body are often more or less im- 
 plicated. The patient suffers from pain and stiffness in the 
 shoulders, or across the loins, or finds himself unable to move 
 his hip, in consequence of pain which he experiences in the 
 muscles whenever he attempts to do so. Thus, whatever the 
 cause of this peculiarity, the fact of its existence admits not of 
 doubt. The articular structures are the parts most commonly 
 affected in acute rheumatism ; the muscles, their fasciae and ten- 
 dons, more generally suffer in the chronic form of the disease. 
 The muscles may be, and sometimes are, implicated in the 
 acute disease, and the joints in like manner are not unfre- 
 quently attacked during the chronic stage of the disorder; but 
 the distinction just alluded to holds good so generally, that in 
 practical importance muscular rheumatism ranks far above all 
 other forms of the complaint, as it occurs in a chronic state. 
 Chronic rheumatism, then, may either be a sequel of an acute 
 
 1 In making tins statement, I do not wish to imply that, in all cases of so- 
 called chronic rheumatism, the disease is identical in its nature and origin with 
 true rheumatism. On the contrary, it is my firm conviction that several distinct 
 diseases, acknowledging ditt'erent origins, and attributable to different morbid 
 poisons, are usually included under the title of chronic rheumatism. I only 
 wish it to be understood that true rheumatism is the same disease, and is trace- 
 able to the same source, whether it assumes an acute or chronic form, or affects 
 one or other tissue of the body.
 
 LUMBAGO. 353 
 
 attack, or may commence at once as an idiopathic disorder, and 
 preserve its character from first to hist. In the former case 
 the joints are rarely free from pain ; in the latter they fre- 
 quently escape altogether. In hoth instances, however, the 
 disease is characterized by a dull aching or uneasiness, which 
 is aggravated or quickened into agonizing pain by sudden mo- 
 tion of the aifected parts, and subsides in some measure after 
 perfect rest. It is rarely accompanied by local heat or redness, 
 and seldom by oedema or by effusion into the joints ; and even 
 when articular swelling does occur, it is unattended by active 
 febrile disturbance. The boundary line, however, between 
 chronic rheumatism and that more active form of the disease 
 which, in the severity of its symptoms, is intermediate between 
 it and acute rheumatism, is often very faintly marked, and thus 
 it sometimes becomes difficult to decide whether a case should 
 be designated chronic rheumatism, or whether it ought not 
 more properly to be classed among those which, as holding an 
 intermediate position, have been entitled cases of subacute 
 rheumatism, and have been treated in accordance with their 
 subsiGute character. 
 
 One of the forms in which chronic rheumatism most fre- 
 quently presents itself in practice is that of lumbago.' The 
 patient who has suffered perhaps from little else than stiffness 
 in various parts of the body, is seized with pain and aching 
 across the loins. So long as he remains quiet, he enjoys com- 
 parative immunity from suffering ; but he undergoes torture 
 whenever, in an unguarded moment, he bends or twists his body, 
 or forgets to observe due caution in moving. Is he lying in 
 bed at the time of his seizure ? he finds it difficult to raise him- 
 self into a sitting posture: is he seated in a chair? he finds it 
 equally difficult to rise on to his feet : and if standing erect, he 
 rarely finds it an easier task to assume a sitting or recumbent 
 posture. To stoop forward is impossible, so agonizing is the 
 pain induced in the muscles and fasciae of the back, which are 
 thus called into action. 
 
 ^ The terras " form " and " variety " are employed as implying simply a dif- 
 ference in the seat, and not in the real nature, of the disease.
 
 354 
 
 CHRONIC RHEUMATISxM. 
 
 When the attack is severe, the unfortunate sufferer may be 
 obliged to remain in bed, or to lie on the sofa, for several succes- 
 sive days ; and, in such cases, there is usually some amount of 
 constitutional disturbance, marked by a coated tongue, accele- 
 ration of the pulse, and acid, dark-colored, or loaded urine. 
 Even when the attack is less severe, it calls no less urgently 
 for relief. For although, in the first instance, the general 
 health may suffer little, the patient can never walk without 
 difficulty, is frequently unable to raise himself into an erect 
 position, and is quite incapacitated for the active duties of life. 
 Moreover, the disease, though not very severe, is apt to be ex- 
 ceedingly obstinate; and, if neglected at first, may linger on 
 for weeks or months in spite of any treatment which may be 
 subsequently adopted. 
 
 Another most annoying form of the disease, which is fre- 
 quently induced by exposure to draughts, is that which affects 
 the muscles of the neck, and constitutes the conplaint which 
 is commonly known by the appellation of a "stiff" or "wry" 
 neck. The pain is much the same as that which characterizes 
 lumbago, and like it is induced or aggravated by motion. At 
 first it may yield readily to appropriate treatment ; but some- 
 times, when neglected, it continues obstinately fixed in one 
 particular spot, and then may give rise to distressing con- 
 sequences. To relax the parts, and so lessen the pain which 
 is caused by the tension of the affected muscles, the patient 
 either holds his head awry, or bends it toward the affected 
 side ; and while in this position, so much of the rigidity of the 
 muscles may ensue as to render it difficult for him to regain 
 his former posture. Such cases are rare ; and, in my expe- 
 rience, have only occurred after repeated attacks, or where 
 the disease has been grossly neglected; but they are sufficient 
 to warn us to lose no time in hastening to our patient's relief. 
 
 Another variety is that which is known as "intercostal" 
 rheumatism. The parietes of the chest, like other parts of the 
 body, are liable to be attacked by the rheumatic poison ; and 
 like them too, when attacked, become exquisitely painful. 
 Motion greatly aggravates the pain. Hence the suffering is
 
 INTERCOSTAL RHEUMATISM. 355 
 
 increased by the act of inspiration ; and the " stitch" which 
 thus results, and which in many respects resembles the stitch 
 of pleurisy, has led to serious mistakes in practice. The 
 patient has been bled, and leeched, and blistered, when no 
 antiphlogistic remedies were required. But intercostal rheu- 
 matism may be readily distinguished from the pain of pleurisy 
 by the absence of fever, which usually marks the invasion of 
 that disease ; by the absence of cough and other symptoms of 
 pulmonary irritation ; by the tenderness which is evinced on 
 external pressure; by the freedom from pain on pressure 
 upward under the short ribs ; by the increase of pain which 
 results from raising the arm above the head; by the relief 
 afforded when the ribs are fixed, and the intercostal muscles are 
 thus kept at rest ; and by the absence of those physical signs 
 of pleurisy which are obtained by percussion, and by the care- 
 ful use of the stethoscope. 
 
 When the disease fixes itself for some length of time in any 
 particular part, as in the muscles of the thigh or arm, it not 
 only occasions pain, but leads to atrophy and wasting of the 
 limb. It does so, not by any change induced in the structure 
 of the parts, nor by any special influence which it exerts over 
 their nutrition, but simply by occasioning such disuse of the mus- 
 cles as naturally leads to their gradual attenuation. Anxious 
 to avoid the pain attendant upon any movement of the affected 
 structures, the sufferer learns to keep them at rest ; and thus, 
 after a time, their nutrition takes place less actively and less 
 perfectly, and they waste, and become gradually weaker and 
 smaller. In all such cases, therefore, though pain be induced 
 at first, much benefit will ultimately result from moving and 
 exercising the affected limbs, as also from employing electricity 
 and friction, and submitting to that more active process of 
 rubbing and kneading which is commonly known as shampooing. 
 
 When the structures which enter into the formation of the 
 joints are affected by chronic rheumatism, pain of greater or 
 less intensity ensues, and varies in its character according to 
 the nature of the parts affected. Very generally the ligaments, 
 and their fibrous structures immediately surrounding the joints,
 
 356 CHRONIC RHEUMATISM. 
 
 are the parts principally if not solely implicated ; and then the 
 old term of "dolor articulorum" represents the extent and 
 character of the affection. There is neither swelling, nor 
 heat, nor redness, but there is a dull aching of the joints, 
 which, when roused and excited by sudden motion, is con- 
 verted into pain of a distressing kind, which sometimes wears 
 off or diminishes in intensity after the parts have been kept 
 some time in exercise. 
 
 When the bursae and the synovial membrane lining the joint 
 become the seat of irritation, and effusion takes place into their 
 cavities, the pain is usually less severe and less constantly 
 aggravated by sudden motion ; but it is more certainly increased 
 by continued exercise, and is most felt when the limbs are in 
 those positions in which the irritated membranes are put upon 
 the stretch. Thus, when there is effusion into the capsular 
 membrane of the knee, pain is sure to be induced by full flexion 
 of the leg, and is greatly relieved by keeping the limb in a 
 horizontal position, and straight, or very slightly flexed. And 
 when the bursse and the adjoining tendinous sheaths are the 
 seat of effusion, any action which tends to bring the parts into 
 play is certain to be accompanied by an increase of suffering. 
 The wrist is one of the common situations of these enlarged 
 bursae, and excessive pain is sometimes occasioned by long- 
 continued use of the affected joint and of the tendons connected 
 with it. In the chronic state, however, which I am now 
 describing, although the swelling may be considerable, there 
 is no remarkable febrile disturbance, no discoloration of the 
 skin, and but little if any perceptible increase of local action. 
 
 One form of the complaint, which is apt to prove extremely 
 obstinate, is that which arises in sequel of urethral discharge. 
 Generally, about the third day of the discharge, the patient 
 feels chilly, and is seized with pain in one or more joints, 
 accompanied by excessive synovial effusion, and by inflamma- 
 tion of the ligaments and the adjoining bursae and sheaths of 
 tendons. Coincidently with the occurrence of articular mis- 
 chief, the discharge sometimes ceases ; but more generally it 
 only decreases in quantity, and a gleety discharge continues
 
 GONORRHEAL RHEUMATISM. 357 
 
 throughout the attack. At first there may be more or less 
 febrile disturbance, but this soon passes off; and though the 
 patient remains crippled by pain and swelling of his joints, and 
 by exquisite pain in the tendons and fasciae whenever he 
 attempts to move, yet his tongue is often clean, his bowels 
 regular, his urine clear, the pulse quiet, the appetite good. 
 These peculiarities, together with the severity of the pains, 
 the obstinacy of their continuance, and the proneness which is 
 manifested to inflammation of the eyes, constitute the chief 
 characteristics of this form of disease. 
 
 I have never known this malady to occur except in persons 
 who were either suffering from urethral discharge, or who — it 
 may be years before — had experienced an attack of rheumatism 
 during the existence of gonorrhoea.^ But I have so often seen 
 it recur in such persons, coincidently with or shortly after the 
 appearance of a slight gleety discharge, which, as far as I 
 could ascertain, was excited solely by excessive sexual inter- 
 course and an undue amount of alcoholic stimulants, that I 
 cannot doubt the predisposition which exists in persons who 
 have once experienced an attack, to a recurrence of articular 
 symptoms on the slightest irritation of the urethra. 
 
 Some persons have maintained that this form of disease is 
 nothing more than ordinary rheumatism excited in a gouty 
 habit, and they have referred to the excessive synovial effusion, 
 the frequency of inflammation of the eyes, and the constant 
 recurrence of the disease coincidently with slight gleety urethral 
 discharge, but without any evidence of active gonorrhoea, in 
 support of their position. My own opinion, however, is opposed 
 to this view. The persons in whom it occurs are often young, 
 slim, and of active habits, who have neither inherited a predis- 
 position to gout, nor acquired the tendency by their own mode 
 of living : the big toe, which is almost always affected in gout, 
 is rarely so in this form of malady ; and colchicum, which 
 
 1 Though I make use of the term gonorrhoea in connection with this form 
 of rheumatism, nij' conviction is that so-called gonorrheal rheumatism arises 
 in connection witii a urethral discharge, which is essentially distinct from that 
 which accompanies ordinary gonorrhoea, and is excited by a peculiar and com- 
 paratively rare form of vaginal poison.
 
 858 CHRONIC RHEUMATISM 
 
 exerts a marked influence over gout, is powerless to restrain 
 the course of this disease, or to modify its intensity. So also 
 are the medicines ordinarily given for the cure of rheumatism. 
 Indeed, I feel persuaded that it has no connection with true 
 gout or true rheumatism, but is a disease sui generis, engen- 
 dered by a specific poison, and requiring a special mode of 
 treatment. • 
 
 There is yet another form of rheumatism which is apt to 
 occur in cachectic conditions of the system, and is well deserv- 
 ing of esp-rcial notice ; I mean that known as periosteal rheu- 
 matism. In those parts of the body where the bony frame- 
 work is thinly covered with integument, the periosteum, the 
 fibrous investment of the bones, becomes painful, tender on 
 pressure, and thickened so as to cause distinct projections. 
 Thus nodes, as they are called, are often formed on the tibia, 
 the ulna, the clavicle, the sternum, and the cranium. At the 
 first onset of the disease, the part affected may become some- 
 what swollen and puffy ; but as the puffiness subsides, the thick- 
 ening to which I have alluded ensues, and forms firm, irregular, 
 painful elevations, exquisitely tender to the touch. So promi- 
 nent are they in some instances, that the eye alone suffices to 
 detect their existence, and even when this is not the case, they 
 are easily felt on running the fingers along the bone. They 
 vary in size, as in prominence, roughness of surface, and 
 tenderness, but they are usually of an inch or an inch and a 
 half in length, suflficiently tender to be a constant source of 
 pain and annoyance, and prominent enough, and rough enough, 
 to be detected on the most cursory examination. 
 
 When they occur on the shin-bone, on the breast-bone, or the 
 collar-bone, thoy are easily recognized, and their nature is not 
 very liable to be mistaken, but their occurrence on the fore- 
 head, or other parts of the cranium, gives rise to a severe and 
 wearing pain, which is often mistaken for ordinary headache, 
 and being improperly treated as such, proves exceedingly obsti- 
 nate and intractable. Patients suffering under this form of 
 disease have repeatedly come under my care at the Hospital, 
 who, for months, have been undergoing treatment for headache
 
 AGGRAVATED BY HEAT. 359 
 
 or neuralgia without deriving the slightest benefit, and in 
 almost all such cases immediate relief has been experienced 
 when the true nature of their complaint has been discovered, 
 and appropriate treatment pursued. 
 
 This form of the disease is frequently described as occurrring 
 only among those who are tainted with venereal poison, or 
 whose systems are saturj^ted by mercury. Nothing, however, 
 can be more erroneous than such a statement. True it is, as 
 already stated, that this form of the complaint is most common 
 in cachectic states of the system, and is, therefore, met with 
 most frequently — nay, almost exclusively — among those who 
 have been depressed by the operation of the syphilitic poison, 
 or by long-continued mercurial action. But it is not necessarily 
 confined to cases of this sort. I have known inflammation of 
 the periosteum occur during the course of a well-developed 
 attack of acute rheumatism, and on several occasions have met 
 with nodes in persons among whom I am convinced no suoh 
 agencies had been at work, and in some of whom it is morally 
 certain they never could have been. Even the existence of a 
 cachectic state of system does not seem to be a condition 
 essential to its development, though the disease is certainly 
 most common among, nay is usually confined to, those in whom 
 a state of cachexia exists. 
 
 The pains in chronic as in acute rheumatism are usually most 
 severe at night ; so much so, indeed, that in many instances, 
 after the first stiffness has worn off in the morning, they occa- 
 sion little inconvenience until the patient is again in bed. These 
 nocturnal exacerbations have been attributed by some to the 
 agency of heat, and the warmth of the bed has been thus made 
 answerable for the manifest increase in the patient's sufferings. 
 But although increased warmth is sometimes accompanied by 
 an increase of pain, yet at others it tends decidedly to its alle- 
 viation ; and the fact that an exacerbation of symptoms toward 
 night is equally well marked in many other disorders, occurs 
 under every condition of external temperature, and is observed 
 as decidedly when the sufferers do not go to bed as when they are 
 lying under a load of blankets, is decisive as to the incorrect-
 
 360 CHRONIC RHEUBIATISM. 
 
 ness of tlie ojjinion which wouhl attribute this pecuh'arity to 
 warmth. 
 
 That, in many cases, tlie pain is aggravated by heat, while 
 in others it is relieved by the same means and to an equal ex- 
 tent, is a matter of common every-day experience, and theo- 
 retically is a fact possessing little value. It accords precisely 
 with the observation which has been made in many complaints 
 in which pain is a prominent feature, namely, that warmth or 
 tepid applications are more grateful in one instance or at one 
 period of the disorder, while cold ones are more grateful and 
 more serviceable at another. But in practice its importance is 
 strikingly manifest, and has been recognized ever since the days 
 of Aretreus. The cases which benefit most from warmth are those 
 which occur chiefly among persons of a languid constitution ; 
 and in such persons friction and stimulating embrocations, 
 together with hot baths, and the internal administration of stim- 
 ulant and sudorific medicines, prove eminently serviceable, and 
 therefore should be resorted to witl40ut delay. But in those in 
 which increase of temperature is productive of suffering rather 
 than of relief, the system has usually appeared more prone to 
 become heated, and to take on inflammatory action. In such, 
 therefore, stimulants should be avoided, and the same principles 
 of treatment adopted as in the acute disease, though, of course, 
 proportioned to the energy and general character of the symp- 
 toms. 
 
 It should be remembered, however, that even when a dry 
 heat is prejudicial to the patient, and greatly increases the 
 severity of his pain, any remedy which gives rise to free perspi- 
 ration is often exceedingly serviceable. In this, as in the more 
 acute form of the disease, I have repeatedly observed and pointed 
 out to the pupils at the Hospital, how a patient who has bitterly 
 complained of the heat which irritated and excited him, so long 
 as the action of the skin was suppressed, has willingly admitted 
 the relief aff'orded by a copious perspiration, resulting from a 
 further increase of temperature induced by a vapor or a hot- 
 air bath. If his pains have not been permanently removed, 
 they have at least\been subdued or mitigated for a time. 
 
 1
 
 TREATMENT BY PARTICULAR MEDICINES. 361 ] 
 
 I 
 
 In the treatment of chronic as of acute rheumatism, it sliould i 
 be remembered that the disease is engendered by a poison result- , 
 ing from imperfect or faulty assimilation, and that no cure can ' 
 be permanent until the materies morbi already generated has 
 been eliminated from the system, and the further formation of 
 such matter arrested. The judicious practitioner should con- V 
 stantly bear in mind hoy^ complicated is the machinery which 
 is out of order, how closely one part of it hinges upon another, 
 and how necessary it is for the cure of his patient that every part 
 should Avork eflSciently. He should endeavor to invigorate the 
 system and restore a normal state of assimilation ; he should 
 mark each deviation from the condition of health, whether indi- 
 cated by the tongue, the pulse, or the skin, by the urine, or the 
 alvine evacuations, and according as the derangement seems 
 general or local, so should he vary and apportion his remedies. 
 Above all he sliould promote a free evacuation through the vari- 
 ous channels by which the effete materials of the body are thrown 
 out of the system ; he should stimulate the skin to the function 
 of perspiration ; he should regulate the action of the kidneys 
 and bowels ; and should endeavor so to modify their several 
 secretions as that every noxious matter shall be got rid of with- 
 out exhausting or depressing his patient. 
 
 One of the remedies which has been found most effective for 
 this purpose, is the ammoniated tincture of guaiacum, either 
 alone or in combination with bark. Ever since the year 1781, 
 when Dr. Dawson published the successful termination of his 
 cases treated by half-ounce doses of this medicine, it has been 
 an established favorite with the profession ; and in the cure of 
 chronic rheumatism, occurring in persons of a languid state of 
 system, its efficacy is quite equal to its reputation. But it is 
 seldom necessary, or indeed expedient, to administer it in such 
 full doses as have been given and recommended by some prac- 
 titioners. Dr. Elliotson, for instance, " has known patients 
 who took six drachms three or four times a day ;"^ and many 
 persons, following Dr. Dawson's example, have given itinhalf- 
 
 ^ Mason Good's "Study of Medicine,-' vol. ii, p. 281. Note by Samuel 
 Cooper. 
 
 24
 
 362 CHRONIC RHEUMATISM. 
 
 ounce doses. My own experience has led me to consider a 
 drachm or a drachm and a half of the tincture, taken three 
 times a day, an ample dose in ordinary cases; and even where 
 this has failed in affording relief, it has never been necessary, 
 nor has it seemed expedient, to exceed two drachms three or 
 four times a day. In doses such as these it usually acts as a 
 stimulating evacuant, increasing thf action of the skin, the 
 kidneys, and the bowels ; and in such doses, should it produce 
 a tendency to diarrhoea, its action may be controlled, and the 
 bowels regulated, by the exhibition of opium. But in larger 
 doses its action is more uncertain. Dr. Elliotson, while as- 
 serting that " when internal stimulants are necessary in rheu- 
 matism, he thinks this one of the best," acknowledges that, 
 ■when given in large doses, "it often purges violently, and some- 
 times produces the nettlerash ;"^ and although no serious con- 
 sequences may ensue, yet the possibility of the occurrence of 
 such troublesome symptoms is enough to make us pause before 
 adopting such a plan of treatment. 
 
 The volatile tincture is particularly useful in chronic rheu- 
 matism from the ease with wliich, if tonics be required, it may 
 be combined with bark and other similar medicines. But the 
 Mistura Guaiaci, to which 1 alluded when considering the treat- 
 ment of acute rheumatism, is also a form in which guaiacum 
 may be employed" advantageously ; the more so, when it is 
 thought desirable to administer it freely without the quantity 
 of the diffusible stimulant which is contained in the larger doses 
 of the tincture. 
 
 There is yet another form, however, in which guaiacum has 
 'earned a well-merited reputation ; I mean in powder, as exist- 
 ing in the compound formerly well known by the title of the 
 ■" Chelsea Pensioner." The original recipe is given below ;^ 
 
 1 Loc. cit. 
 
 2 Take of Flowers of Sul[)liur, jij ; 
 
 Cream of Tartar, §j ; 
 Powdered Rhubarb, 5ij ! 
 Guaiacum. 3J i 
 Clarified Honey, lb j ; 
 
 One Nutmeg finely powdered. Mix the ingredients. 
 Two large tea^pooDfuIs to be taken night and morning, and to be persevered
 
 TREATMENT BY PARTICULAR MEDICINES. 363 
 
 and in tliese, or in somewhat varying proportions, this medi- 
 cine has repeatedly effected a cure after all other preparations 
 have been tried in vain. In most instances, however, the pro- 
 portion of guaiacum may be advantageously increased, and 
 when the bowels are costive, fifteen, twenty, or even thirty 
 grains may be given at a dose. It is especially useful in old 
 lingering cases, accompanied by torpor of the intestinal secre- 
 tions, and a sluggish, inactive condition of the skin. 
 
 On the same principle as that on which guaiacum has been 
 recommended, many other remedies of a warm and stimulating 
 nature have been administered in obstinate lingering cases. 
 Among these may be mentioned Camphor, the oils of Turpen- 
 tine, Cajeput, Juniper, Sassafras, and Amber, the balsams of 
 Copaiba and Peru; and aromatic and pungent plants, such as 
 mustard, horseradish, and the Arnica Montana.^ Mezereon is 
 sometimes used, and Senega and Dulcamara have also been 
 recommended. All these agents, either alone or in combina- 
 tion with opium, which often proves a valuable adjunct, have 
 been found extremely serviceable, and none more so than oil 
 of turpentine. Indeed, many of the medicines just enumerated 
 are of a terebinthinate nature, and were it not for its nauseous 
 flavor, and for the strangury which often follows its use, the 
 common oil of turpentine, administered in drachm or half 
 drachm doses, would be very generally adopted as a cure in 
 obstinate and protracted cases. In combination with bark, I 
 have sometimes known it particularly useful. 
 
 Sassafras is a remedy which is seldom given in this country, 
 except in the combination which finds a place in our Phaima- 
 copocia under the title of Decoctum Sarzte Compositum. I am 
 satisfied, however, that it may be administ red advantageously 
 in many instances in which sarsaparilla ie not needed, and in 
 doses exceedinor those in which it is taken in the Pliarmaco- 
 poeia preparation just alluded to. When the circulation has 
 
 in until the wliole is consumed. For the first three iiights, a large tumbler of 
 warm rum and water to be taken at bedtime, or, il fever be present, white 
 wine instead of rum. 
 
 ' For formula, see p. 322.
 
 364 CHRONIC RHEUMATISM. 
 
 been languid, the skin dry, and the kidneys, liver, and bowels 
 inactive, as they are in many forms of chronic rheumatism, the 
 greatest benefit frequently results from its use either alone 
 or in conjunction with any other remedies which the circum- 
 stances of the case may seem to require. It is stimulant and 
 sudorific in its action, and in certain instances appears to exer- 
 cise a curative influence, Avhich is not possessed by guaiacum 
 nor by any other remedy of the same class. Moreover, it is 
 not purgative like guaiacum, and, consequently, is available in 
 many instances in which the administration of that medicine is 
 inadmissible.^ 
 
 Whenever it is given, diluents, such as hot weak tea, barley 
 water, or even plain water, should be taken plentifully, with 
 the view of promoting diuresis and perspiration ; and this ap- 
 plies not only to the whole class of stimulating and sudorific 
 medicines of which this is one, but also to the saline medicines, 
 which in rheumatism and rheumatic gout are given as alteratives 
 and eliminatives. There cannot be a doubt that free dilution ex- 
 ercises a most important influence on the action of almost all the 
 remedies which prove useful in this class of disorders, and that a 
 dose which would excite nausea and irritation of the stomach 
 when taken in a concentrated form, is often productive of ex- 
 cellent results Avhen aided in its action by water. Hence, 
 probably, the wonderful efficacy of the natural mineralized 
 waters, and hence, also, the superior effects which often ensue 
 after taking the weak infusions or teas which are the favorite 
 remedies of the poor and the nostrums of so-called herbalists. 
 I am firmly convinced that . our medicines frequently fail in 
 their operation for lack of sufficient dilution ; and, although I 
 do not counsel their administration in an inconveniently bulky 
 form^ I do most strongly urge the taking of a copious draught 
 of water or some harmless diluent after each dose of the 
 remedy. 
 
 ' The subjoined formula is one which may be employed : 
 J^. Sassafras Radicis concisi, §iss ; 
 Mezerii, 5'v ; 
 
 Taraxici Radicis concisi, §iij ; 
 Aquaj ferventis, Oj. 
 Macera per horas tres et cola. Dosis Liquoris colati, ^j to ^iss.
 
 TREATMENT BY PARTICFLAR MEDICINES. 365 
 
 Sulphur is an agent which sometimes proves peculiarly val- 
 uable in the treatment of chronic rheumatism, especially when 
 the skin is inactive. Among the poor it has long been a 
 favorite remedy, and by its action has doubtless contributed not 
 a little to the reputation of the powder termed the " Chelsea 
 Pensioner,"^ of which it forms a large proportion. Adminis- 
 tered in half-drachm doses three or four times in the course of 
 the day, and aided in its action by the stimulating effect of the 
 simple vapor or the sulphur vapor bath, it is often extremely 
 efficacious in removing chronic' muscular pains, and there are few 
 remedies within the range of the Pharmacopoeia on which so much 
 reliance can be placed. Its use, however, should be restricted 
 to muscular and neuralgic rheumatism ; for in the articular 
 form of the disease, accompanied by synovial effusion, and in 
 periosteal rheumatism, it is far inferior to other remedies, if, 
 indeed, it be not altogether valueless. 
 
 Colchicum is of far less service in chronic rheumatism than 
 in the more active form of the disease, and its administration 
 should be restricted to those cases in which the liver is inactive 
 and in which the joints are swollen, with effusion within the 
 capsule, and the pain is aggravated by heat. Under such cir- 
 cumstances, in combination with alkalies, diuretics, and opiates, 
 it sometimes proves exceedingly beneficial. 
 
 The valuable properties of iodide of potassium are seldom 
 displayed when the muscular structures are the parts affected ; 
 but they are strikingly manifest when the patient is out of 
 health and the periosteum is implicated. In such cases, admin- 
 istered in five or eight grain doses, it speedily gives relief, not 
 unfrequently removing the pain and swelling in the course of 
 a few days ; and even when the disease proves more intractable, 
 and lingers on for several weeks, the intensity of the pain is 
 soon subdued, and the patient's health gives tokens of improve- 
 ment. Indeed, so potent is the influence' of this medicine over 
 this particular form of the disease, that in many instances the 
 cure may be safely intrusted to its unassisted powers ; but in 
 old-standing cases, where the health is much impaired, it is 
 
 » See p. 362.
 
 366 * CHRONIC RHEUMATISxM. 
 
 advisable to combine it Avith bark and sarsaparilla, and to ex- 
 hibit a full dose of opium at night. The bowels, in such a case, 
 should be regulated by gentle laxatives, and the general health 
 sustained by a full and nutritious diet. 
 
 A valuable adjunct to the iodide of potassium in many of 
 these cases is the bark of the Daphne Mezereon. This remedy 
 was introduced to the notice of the profession by Dr. Alexan- 
 der Russell,^ as an efficacious cure for venereal nodes, and in 
 small doses is frequently administered in the compound decoc- 
 tion of sarsaparilla, of which it forms one of the ingredients. 
 But however valuable its properties may be, and their value in 
 many instances is undoubted, they cannot be exerted to any 
 advantage in the small doses in which it is usually exhibited, 
 and,- therefore, whenever it seems desirable to give it, either 
 alone or in conjunction with sarsaparilla, an infusion should be 
 made of half an ounce of the root to a pint of water. This 
 when strained may be given in doses of an ounce or an ounce 
 and a half, in conjunction with the iodide and extract of sar- 
 saparilla ; and though it does not possess the power attributed 
 to it by Dr. Russell, of curing secondary syphilis, it certainly 
 proves stimulant, diaphoretic, and alterative, and, in many 
 instances, is said to produce effects such as cannot be obtained 
 from the iodide alone. In purely muscular rheumatism, it 
 sometimes exerts a beneficial influence, but its good effects are 
 most strikingly displayed in the class of cases which are ben- 
 efited by Iodide of Potassium. 
 
 The late Dr. Percival was in the habit of prescribing the 
 cod-liver oil in chronic rheumatism; and Dr. Bardsley, in his 
 valuable medical reports, speaks favorably of its curative influ- 
 ence. I have sometimes administered it alone in half-ounce doses 
 when the patient has been thoroughly out of health ; and in some 
 such cases with undoubted benefit. But, under ordinary circum- 
 stances, its efficacy appears to be greatly increased by its exhibi- 
 tion in conjunction Avith other remedies, and therefore whenever 
 a case occurs in which, from the cachectic condition of the pa- 
 tient, its administration seems likely to be attended with benefit, 
 
 ' See " Medical Observ. and Inquiries," vol. iii, p. 194.
 
 TREATMENT BY PARTICULAR MEDICINES. 367 
 
 I usually give it in the form of an emulsion with the Liquor 
 Potassne and Iodide of Potassium; or else combine it, if circum- 
 stances permit, with the syrup of the Iodide of Iron. When 
 the appetite is indifferent, the circulation languid, and the pulse 
 weak, the Sulphate of Quinia, in combination with the mineral 
 acids, aided, if necessary, by some preparation of Iron, has ap- 
 peared to me a more useful addition than the Liquor Potassse 
 and Iodide of Potassium. 
 
 Hydrochlorate of Ammonia is a remedy of singular efficacy 
 in chronic rheumatism, yet, strange to say, is almost unknown 
 as such to the profession. In no treatise on rheumatism which 
 I have had an opportunity of consulting, do I find the slightest 
 notice of its virtues. Yet its action on the skin is admitted by 
 those who have watched the effects of its internal administra- 
 tion. Sunderlin reports, that it acts as an "excitant" to the 
 bowels, the skin, and the kidneys ; that " it not only increases 
 secretion, but improves nutrition and assimilation," and "pro- 
 motes not only the mucous secretions, but also cutaneous exha- 
 lation."^ Certain it is, that in fifteen or twenty grain doses, 
 in combination with bark, it sometimes produces marvelously 
 good results, and is frequently serviceable when other remedies 
 have proved inefficient. The character of the secretions im- 
 proves under its influence, the skin acts more freely and regu- 
 larly, and the disease gradually subsides. Its beneficial effects, 
 however, are most remarkably exerted in muscular rheumatism : 
 and when the periosteum or the joints are affected, it seldom 
 afi"ords us much assistance. 
 
 Arsenic is another remedy which in obstinate cases charac- 
 terized by dryness and harshness of the skin is often produc- 
 tive of excellent effects, improving the health, augmenting the 
 appetite, stimulating the capillary circulation, and restoring 
 tiie natural perspiratory action. Its antirheumatic virtues, 
 however, are as yet but little known to the profession, and it 
 was mere accident which first directed my attention to it. In 
 November, 1853, a gentleman consulted me respecting rheu- 
 
 1 " Handbuch der Speciellen Hulmeltellelire." Quoted iu Pereira's " Alateria 
 Medica."
 
 368 CHRONIC rheumatism. 
 
 matic pains in tlie joints, whicli had tormented him more or less 
 for seven years. These pains had supervened on an attack of 
 articular rheumatism, which lasted three weeks, and was accom- 
 panied by pain, heat, and swelling of ihe affected parts. The 
 inflammatory symptoms had never since returned, nor had there 
 been more than an occasional tumefaction for a few days ; but 
 lately the pains had been unceasing, and had given rise to 
 excessive stiffness and soreness of the whole body, especially 
 of the joints. He had taken guaiacum, mercury, iodide of 
 potassium, sarsaparilla, and all the ordinary remedies for rheu- 
 matism, and had tried the effect of baths and mineral waters in 
 this country and on the Continent. Under these circumstances 
 I was at a loss what medicine to prescribe, but finding that 
 the pains were of a somewhat intermittent character, I tried 
 full doses of quinine in the first instance, and subsequently, as 
 they failed, administered arsenic. The pains soon yielded, the 
 appetite improved, and I had the satisfaction of seeing my 
 patient regain his health. Since that time I have prescribed 
 it in several instances with good effect; and although, as stated 
 at p. 320, when speaking of its action on rheumatic gout, I do 
 not feel quite satisfied as to its modus operandi, and am unable 
 as yet to point out the precise conditions under which its bene- 
 ficial influence is most likely to be exerted, the impression is 
 strong in my mind that the cases which derive most benefit 
 from its administration are those in which the skin is inactive, 
 the bowels regular, the kidneys healthy, and the urine clear, 
 but of low specific gravity — in cases, in fact, characterized by 
 want of tone and nervous energy in the system. My experi- 
 ence, however, is at present very limited, and the grounds for 
 an opinion therefore very imperfect, and I shall be glad to 
 receive information on the subject from any one who will kindly 
 favor me with it. 
 
 In some obstinate cases of chronic rheumatism, more espe- 
 cially when supervening in a system which has been poisoned 
 by the syphilitic virus, it is expedient to have recourse to the 
 exhibition of mercury. Indeed, many such cases are absolutely 
 incurable until its agency is employed ; and in such instances
 
 TREATMENT BY PARTICULAR MEDICINES. 369 
 
 its administration is speedily productive of good effect. Within 
 the last four years I have known several patients recover rapidly 
 under the use of various antirheumatic remedies, in which they 
 had fruitlessly persevered for months prior to the exhibition of 
 a mercurial. But, in ordinary cases, mercurialization is need- 
 less, if not hurtful. It sometimes proves useful when there is 
 excessive tenderness with pufBness about a periosteal swelling, 
 as also when a joint is enlarged, and continues in a state of 
 irritation uninfluenced by other remedial agents, but it is always 
 depressing, and should not be employed unless its influence is 
 demanded either by the urgency of the local symptoms or by 
 the failure which has attended the administration of other rem- 
 edies. If the local symptoms are severe, it may be necessary 
 to push it gradually to salivation, but in other instances it is 
 desirable to obtain its specific influence without the depression 
 occasioned by ptyalism. For this purpose the bichloride of 
 mercury, or the biniodide,^ formed by adding the iodide of 
 potassium to the Liq. Hydrarg. Bichloridi, prove very efficient 
 agents, and pains which have long resisted every other remedy 
 will often yield rapidly to their influence. Indeed, the binio- 
 dide kept in solution by an excess of iodide of potassium, and 
 given in combination with bark, has proved in my hands the 
 most valuable of all medicines in rheumatism which has super- 
 vened in a system tainted by the syphilitic poison, and in 
 several instances has eff"ected a speedy cure after the bichlo- 
 ride had been given in vain. Occasionally it produces slight 
 griping and diarrhoea, but these symptoms are easily con- 
 trolled, and cease directly the medicine is discontinued, or 
 is exhibited in smaller doses. The possibility of their occur- 
 rence, therefore, forms no bar to its administration in appro- 
 priate cases, and its curative action is so strongly marked, and 
 
 1 The following are forrmilaj I often employ : 
 ^. Liq. Hydrar Bichloridi, 3J-3'J j ^i"' Liq. Hydrar. Bichloridi, 3i-3'j ! 
 
 Potassii lodidi, gr. v-x ; Potassii lodidi, gr. v-x ; 
 
 Extract! Sarzoe, 3ss-3J ; Syrupi Sarzoa, 3'j-3''j i 
 
 Decocti Cinchona?, §iss. Tincturae Cinchonae Co., 3'-3'J ! 
 
 M. ft. Haustus. Decocti Cinchonae, ad. ^iss. 
 
 M. ft. Haustus.
 
 370 CHRONIC RHEUMATISM. 
 
 SO speedily produced, that I never hesitate to recommend its 
 exhibition whenever its agency is required. 
 
 Opiates seem especially called for in chronic rheumatism, by 
 the obstinacy and weariiig nature of the pain, and certainly, in 
 some instances, their influence for good appears to extend not 
 only to temporary abatement of suffering, but to the subjuga- 
 tion of that action on which the pain and suffering depend. In 
 my experience, however, this rarely has been the case. Gen- 
 erally they have done little more than assuage present pain, and, 
 by obtaining for the patient a respite from suffering, afford him 
 that rest which is as essential to the recovery of his health as 
 to his hourly personal comfort. This, then, is the vieAV with 
 which they should be administered, and their exhibition there- 
 fore should be limited to cases in which Morpheus is a stranger, 
 and must be wooed before he will lend his assistance. Battley's 
 sedative solution and the Morphia Acetas are admirable and 
 efficient preparations, but in no form do opiates prove more 
 serviceable in this complaint, than in that of the celebrated 
 Dover's powder, the Pulvis Ipecacuanhge Compositus of the 
 Pharmacopoeia. 
 
 Sometimes, however, opiates disagree with the stomach, or 
 fail in giving relief. In either case, recourse may be had to 
 other sedatives, which, under certain circumstances, prove more 
 efficacious than the preparations of opium. This is so especially 
 when the pain assumes a neuralgic character. Cases, for instance, 
 Avhicli have long resisted opium and the various preparations 
 of morphia, have yielded as if by magic under the influence of a 
 full dose of belladonna. The same may be said of stramo- 
 nium, conium, and hyoscyamus. But in no instance have I seen 
 more speedy or more complete relief from suffering than has 
 sometimes followed the exhibition of the ethereal tincture of 
 the Cannabis Indica. In one patient, a medical friend, whom 
 I was not asked to see until after all ordinary sedatives had 
 been tried, a single dose of the tincture gave immediate relief, 
 and was followed by a long refreshing sleep, to which he had 
 been a stranger above two months. A similar effect, though 
 less strongly marked, has resulted from its use in many other
 
 TllEATMENT BY PARTICULAR MEDICINES. 371 
 
 instances. But great caution must be 'observed in the employ- 
 ment of this remedy. If it fails in producing a narcotic effect, 
 it is apt, even in doses of twelve or fifteen minims, to produce 
 considerable excitement, and its use, therefore, should be 
 restricted to cases accompanied by nervous exhaustion. Indeed, 
 its assistance appears to be called for in the very cases in which 
 opium, belladonna, and other pure narcotics, not unfrequently 
 prove useless ; while in cases characterized by nervous excite- 
 ment, and accompanied by a hot skin or a hurried pulse, its 
 action proves hurtful rather" than beneficial. 
 
 There is yet another sedative which deserves especial notice 
 as being remarkably serviceable in many forms of chronic 
 rheumatism. I allude to aconite, a remedy which was intro- 
 duced by Stoerk, of Vienna, in 1762, and was largely used in 
 this country by the late eminent Dr. Pitcairn, of St. Bartholo- 
 mew's Hospital. Within the last seven years I have prescribed 
 the tincture in a large number of cases; and in many which 
 were unattended by redness and swelling, its remedial efi"ects 
 have been strongly marked. If, in some instances, it has not 
 exercised any control over the violence or duration of tlie pain, 
 it has acted almost magically in others, and relief has followed 
 as speedily after its exhibition, as it does not unfrequently 
 after its external application. Sometimes it produces a sen-, 
 sation of heat and tingling in the extremities, constriction 
 across the throat, and a constant desire to swallow; but unless 
 such symptoms are persistent, and accompanied by vertigo, 
 faintness, palpitation, or some other disagreeable sensation, it 
 is not necessary on that account to discontinue its exhibition. 
 When the secretions are out of order, and the general health 
 is impaired, it rarely proves eflficacious until other medicines 
 have been administered; but in many cases of chronic rheu- 
 matism, unconnected with a venereal taint, when the symptoms 
 are those of aching pain and stiffness, without any redness or 
 swelling of the parts, or any notable derangement of the secre- 
 tions, it' is valuable beyond all other remedies we possess. 
 Observation, however, has led me to believe that it is useless 
 to persevere in its administration, if some relief be not speedily
 
 372 CHRONIC RHEUMATISM. 
 
 obtained; whereas, if it prove sedative in its action, its use 
 should be persisted in, and the dose cautiously increased. Dr. 
 Mantell, of Bath, who has used it extensively during the last 
 twenty-five years, and has kindly favored me with the result 
 of his experience, reports most favorably of its curative influ- 
 ence. 
 
 Aconite is said to be diuretic and diaphoretic in its action ; 
 but although undoubtedly it often excites perspiration, it has 
 so rarely displayed any diuretic qualities in the cases which 
 have fallen under my observation, that I suspect the occurrence 
 of diuretic symptoms has been a mere coincidence. Five or 
 six minims of the Pharmacopoeia tincture may be given in the 
 first instance, twice or three times a day, and may be gradu- 
 ally, but cautiously, increased to ten or even twelve minims. 
 But considerable difference exists in this respect, according to 
 the degree of care which has been exercised in preparing the 
 tincture, and to the combination in which it is administered. 
 For although the dose of the tincture ordinarily met with in 
 the shops may be increased, in some instances, to -ten or even 
 twelve minims, such is rarely, I may almost say never, the 
 case in regard to a carefully prepared tincture. So, again, if 
 the tincture be given in combination with alkalies, the aconi- 
 ,tine is precipitated, and unless great acidity exist in the 
 stomach, the remedy is rendered almost inert; whereas, given 
 in conjunction with a few drops of dilute sulphuric acid, its 
 solubility is insured and its full power is exerted. Hence it 
 must not be inferred, because ten or twelve minims are readily 
 borne when taken in an alkaline mixture, that the same dose 
 may be administered with impunity if the alkalies are omitted, 
 and the mixture is made eitiier acid or neutral. I have known 
 one instance in which disagreeable effects were thus produced, 
 and can well conceive it possible for dangerous symptoms to 
 supervene. Therefore, in a matter of so much importance, I 
 deem it advisable in every instance to administer aconite in an 
 acid mixture, in order that the full strength of the dose may 
 be felt at once. Further, I always think it right to insist that 
 ■wherever the mixture is dispensed in the first instance it shall
 
 TREATMENT BY PARTICULAR MEDICINES. 373 
 
 be made up for the future, so as to insure a uniformity in the 
 strength of the tincture, and consequently in the dose of the 
 medicine. 
 
 In that form of disease which is known as lumbago, brisk 
 purgatives are some of our most efficient allies, and usually 
 should be made use of at the commencement of the attack in 
 conjunction with alkalies and diuretics. Their efficacy, how- 
 ever, varies according to the amount and character of the 
 alvine and urinary secretions. When the urine is scanty, 
 high colored, or loaded, the bowels costive or the dejections 
 dark colored and offensive, they are almost always of inesti- 
 mable service, and a large turpentine and castor oil enema, or 
 a few doses of colocynth and calomel, administered at bedtime, 
 followed each morning or on alternate days by a black draught, 
 containing half an ounce of the potassio-tartrate of soda, and 
 thirty minims of colchicum wine, have often gone far toward 
 effecting a cure. But when the urine is abundant and light 
 colored, the bowels regular, and the dejections natural, the 
 value of purgatives is not so apparent. Indeed, so little benefit 
 has usually resulted from their employment in such cases that 
 I now very rarely have recourse to their administration. In 
 the former instances, the pain is probably connected more or 
 less intimately with irritation of the lumbar and sacral nerves, 
 and this is relieved, not only by the full evacuation of the 
 bowels which follows the use of purgatives, but by the change 
 induced in the character of the secretions. In the latter, the 
 lumbar muscles and their fasciae and tendons are the parts 
 principally affected, and hence the remedies adopted for their 
 relief should have relation to their superficial position, and to 
 the more purely neuralgic character of the pain. Though 
 internal remedies should not be neglected, our main reliance 
 must be on local applications. If the urine be turbid, and the 
 case be attended by symptoms of local congestion, cupping on 
 the loins is of essential service, and dry cupping may be often 
 employed beneficially when it is not thought desirable to 
 abstract blood. Baths are also valuable agents, particularly 
 the warm bath, rendered alkaline by the addition of carbonate
 
 374 
 
 CHRONIC RHEUMATISM. 
 
 of soda or potash, as are also fomentations, formed by placing 
 across the loins flannel wetted with an alkaline and opiate solu- 
 tion, and covered with a piece of flannel. When, on the other 
 hand, there are no symptoms of local congestion, and the case 
 appears to be of a neuralgic character, electricity and galvan- 
 ism may be tried with a fair prospect of affording relief. In 
 such cases the continuous current should be employed, and it 
 cannot be applied more satisfactorily than by means of one of 
 Pulvermacher's chain batteries. Stimulating embrocations, 
 followed by sedative fomentations kept constantly applied to 
 the loins, ^ are also very useful in obstinate cases, as are also 
 mustard poultices, and plasters of a stimulating or of a sooth- 
 ing character. In some instances, after the more active symp- 
 toms have subsided, friction with the naked hand, with a French 
 flannel brush, or with a horse-hair glove, followed by a simple 
 flannel bandage covered with oiled silk to prevent evaporation, 
 or a band of Markwick's epithem worn across the loins, is suffi- 
 cient to afford permanent relief. 
 
 A useful external application in Lumbago, as well as in Stiff"- 
 neck and other forms of muscular rheumatism, is that which 
 has been termed Sir Anthony Carlisle's blister, an agent com- 
 paratively unknown to the profession. It consists in the appli- 
 cation to the skin, over the afiected part, of a small flat iron, 
 gently heated in a spirit-lamp or boiling water. The operation 
 is completed in a few seconds, is productive of little or no pain, 
 
 ' Subjoined are two very useful forms of applications in these cases : 
 ^. Olei Cajeputi, vel Olei Origani, vel Olei Succini, 5^; 
 Olei Terebinthinne, 5^'^ 
 
 Linimenti Ammoniie, vel Tinctura; Aconiti, 3^j- 
 M. ft. Linimentum. 
 
 I^. Liquoris Opii Sedativi, ^i; 
 Extract! Belladonnoe, 5'; 
 Glycerini, §iss; 
 Tincturas lodinii Co., 3'^- 
 M. ft. Lotio pro lumborum fotu adhibendar. 
 To the former may be added 3'^' of the Tincture of the Arnica Montana, 
 which is oftentimes of the greatest service ; but if its assistance is had recourse 
 to, it will be necessary to watch closely the effect produced on the skin, inas- 
 much as a very troublesome eruption is apt to result when its use is long per- 
 severed in.
 
 TREATMENT BY PARTICULAR MEDICINES. 375 
 
 and is immediate in its effects. Among the poorer classes of 
 the community, the practice of ironing the painful part with a 
 laundress's iron, the skin being covered with a piece of thin 
 flannel or brown paper, had long been in vogue in various 
 forms of muscular rheumatism, but it was not till the year 
 1826, when Sir Anthony Carlisle addressed a letter to Sir Gil- 
 bert Blane, describing the benefits derivable from the appli- 
 cation of a hot iron to the naked skin, and recommending a 
 peculiar form of instrument for the purpose, that the attention 
 of the profession w^as directed to the subject. Of late years, 
 Dr. Corrigan, of Dublin, and Dr. Day, of St. Andrews, have 
 borne additional testimony to the value of this remedy, and 
 have published a series of cases successfully treated by its 
 means ; and to these gentlemen the profession is indebted for 
 the revival of an obsolete, though useful practice. 
 
 The instrument recommended by Dr. Day^ "is a metal but- 
 ton, about half an inch in diameter and a quarter of an inch in 
 thickness, connected by an iron shank Avith a small wooden 
 handle. The whole instrument," he says, "resembles a very 
 small hammer. On heating the button, which is effected in 
 about a quarter of a minute by the flame of a spirit-lamp, I 
 place the end of the forefinger on the curve. When the heat 
 becomes uncomfortable to the finger, the instrument is ready 
 for use. Dr. Corrigan's mode of applying it is to touch the sur- 
 face of the part affected, at intervals of half an inch, as lightly 
 and rapidly as possible. I have usually found more service 
 from very lightly drawing the flat surface of the heated but- 
 ton over the affected part, so as to act on a greater extent of 
 surface. The cuticle is never raised, and the only visible effect 
 is a slight degree of local redness, either in lines, according to 
 my plan, or in circular patches, if Dr. Corrigan's directions are 
 folloAved." Dr. Day concludes by expressing his opinion " that 
 the practitioner who will give the thermic treatment a fair trial 
 will not readily abandon a remedial agent by which human 
 suffering can be so easily and rapidly alleviated." In advo- 
 cating the use of his favorite remedy, Dr. Day asserts^ that 
 ^ Day, " Oa Diseases of Advanced Life." Appeiidix. * Loc. cit.
 
 376 cnRONic rheumatism. 
 
 he " never met with a case of lumbago which did not completely 
 yield to three or four of these trivial operations." But judging 
 from my own very limited experience in the use of this appli- 
 cation, I should say that it often fails in affording relief, and 
 proves useful in exact proportion as the pain is truly neuralgic. 
 In lumbago, accompanied by scanty, loaded urine, a coated 
 tongue, costive bowels, and other symptoms of constitutional 
 derangement, I have never found it of the slightest service 
 until after these symptoms have been subdued, and the same 
 holds good in other forms of muscular rheumatism. But when 
 the pain has appeared referable to the continued local eifcct of 
 a formerly existing cause of irritation, or when from the first 
 it has been of a purely local and neuralgic character, and 
 unaccompanied by constitutional disturbance, then the hot iron 
 has well sustained its character, and in some instances has 
 afforded instantaneous relief. Indeed, I know of no remedy to 
 which we can have recourse in such cases with a better pros- 
 pect of relief; but I question whether the instrument recom- 
 mended by Dr. Day is as efficacious as a laundress's small box- 
 iron, or one of the irons used by chemists for spreading plaster, 
 with either of which the limb may be ironed while the skin is 
 covered with a piece of brown paper or thin flannel. Certain 
 it is that in one case in which Dr. Day's little button had proved 
 utterly useless, a common laundress's iron gave instant relief, 
 a result which I attributed to the much larger surface subjected 
 to heat in the latter instance. 
 
 In striking contrast with this thermic mode of treatment is 
 the frigorific plan suggested by Dr. James Arnott. He recom- 
 mends that a freezing mixture should be applied to the back 
 for the space of four or five minutes, or until complete anaes- 
 thesia of the parts is produced, and he states that in three only 
 out of nine cases in which he employed this remedy, was it 
 found necessary to apply it a second time.^ The mode of using 
 this remedy is more particularly described in my chapter on 
 Sciatica, and it is only necessary here to state that the appli- 
 cation, though somewhat painful, and occasioning a degree of 
 1 " Od Neuralgic, Rheumatic, and other painful Affections," p. 29.
 
 TREATMENT BY PARTICULAR MEDICINES. 377 
 
 redness or congestion which continues for a few hours, or even 
 days afterward, according to the duration of the freezing and 
 other circumstances, is not productive of dangerous results, 
 and may therefore be tried when other and milder remedies 
 have failed. But it is often looked upon with dread by the 
 patients, and sometimes occasions excessive and enduring ten- 
 derness of the parts ; and therefore I would not counsel its 
 employment until the catalogue of other remedies has been 
 exhausted. 
 
 Unfortunately, I have had so few opportunities of noting 
 its eiFects, that my testimony as to its action is not of much 
 value. In two instances accompanied by loaded urine and 
 constipation, it utterly failed in influencing the pain ; in 
 another, which was unaccompanied by feverish symptoms, 
 immediate relief resulted from its application ; and in two 
 others of a similar nature, relief was experienced, but a cure 
 was not eifected by the first application, and the patients 
 refused to submit to a second trial of its virtues. 
 
 From such limited observations no legitimate inference is 
 fairly deducible, but I can readily conceive that where lumbago 
 is connected with a purely neuralgic condition of the superficial 
 fasciae or the muscular structures, or even with congestion of 
 such parts unaccompanied by derangement of the secretions, 
 the powerful influence of a very low temperature may deaden 
 the sensibility of the nerves, lull the pain, and even put an end 
 to the local congestion. But I cannot understand how any 
 such agency can relieve the disease when arising, as it often 
 does, in connection with disordered secretions, loaded bowels, 
 or constitutional derangement; and although I am unwilling to 
 rest my argument upon the two unsuccessful cases of this sort 
 above referred to, I think it fair to adduce them in support of 
 what appears to be a sound physiological vicAV. Experience, 
 however, is better than theory, however specious, and I shall 
 be glad if further observation, or the well-attested experience 
 of others, enables me hereafter to modify my opinion. 
 
 Of internal remedies, none prove more useful ^hen the 
 bowels are regular, and the urine is clear and abundant, than 
 25
 
 378 
 
 CHRONIC RHEUMATISM. 
 
 Oil of Turpentine, and few are found less serviceable when 
 the bowels are costive and the urine is high colored and loaded. 
 Administered in half-drachm or two-scruple doses, either in a 
 draught, or in the form described below,' it is an agent on 
 which the greatest confidence may be placed, and case after 
 case has been admitted under my care at St. George's Hospital, 
 in which it has effected a rapid cure, after Guaiacum and other 
 remedies had been tried in vain. The only serious objection to 
 its use is the possibility of its giving rise to strangury and 
 nephritic irritation, but if care be taken in watching its effects, 
 no apprehension need be entertained on this score. The mere 
 possibility, however, of its causing such symptoms would, of 
 course, deter a cautious practitioner from recommending it to 
 a patient to whom he was unable to pay frequent visits. 
 
 Stiff-neck is benefited by the same sort of local remedies as 
 Lumbago. Though in some few instances leeches may be 
 needed, yet more generally, friction, with opiate and stimulat- 
 ing embrocations, followed by warm fomentations, to the part, 
 proves quite efficient. When the disease is of recent occur- 
 rence, a few drops of Chloroform or Chloric ^ther may be 
 held to the part in the palm of the hand, until redness of the 
 skin is produced. In several instances in which the chloroform 
 has been so employed, the relief afforded has been immediate, 
 and, after two or three applications, has remained permanent ; 
 but when the complaint is of long standing, friction is of greater 
 service. 
 
 The beneficial influence of baths is nowlicre, perhaps, dis- 
 played more strikingly than in clironic rheumatism. The 
 warm bath, either alone or rendered alkaline by potash or soda, 
 the hot air bath, and the vapor bath have each their respective 
 merits. The latter two have always appeared to me the most 
 efficient agents for forcing perspiration, and relieving the 
 symptoms in those cases in which the pain is aggravated by 
 warmth; whereas the warm bath, at a temperature of at least 
 
 ' Spiritus Terebinth inse, 
 Mucilaginis Acuciae, 
 Mellis, ia partes ajquales. 
 M. ft. Electuarium cujus sumatur cochlearium unum Theaj ter die.
 
 BENEFICIAL EFFECT OF LOCAL REMEDIES. 379 
 
 100°, has been equally if not more beneficial to those in whom 
 warmth proves grateful and sedative. It must be remembered, 
 however, that the vapor and hot-air baths have the great ad- 
 vantage of being applicable while the patient is lying in bed, 
 and this, in some instances, may be a sufficient recommenda- 
 tion to determine their employment in preference to the water 
 baths. 
 
 In those to whom cold does not prove chilling, and in whom 
 proper reaction ensues after the shock, the shower bath, more 
 especially of salt water, is frequently of essential service, and 
 its good effects are increased when reaction is maintained by 
 friction. Local baths, as by a douche of water, are also 
 powerful assistants, the more so as they can be employed 
 repeatedly, and can be directed to the immediate seat of pain. 
 Should all these fail, the mysterious agency of the Bath, Ilar- 
 roirate, or Buxton waters, of the Wood Hall Iodine and Bro- 
 mine Spa, or of the Droitwich saline bath, may be resorted to, 
 or the patient may be sent to some of those continental thermal 
 springs whose virtues were discussed in a previous chapter.^ 
 
 Blisters have been recommended, and are frequently era- 
 ployed for the relief of chronic rheumatic pains, and, as with 
 other remedies, their repute has varied according as they have 
 been made use of properly or improperly. In muscular rheu- 
 matism they are seldom of much service, and arc rarely if ever 
 necessary ; and, in articular rheumatism, are never needed, 
 unless the pain has been long fixed in one particular joint, and 
 some thickening or enlargement has gradually taken place. 
 But in periosteal rheumatism they are extremely serviceable, 
 more especially when there is thickening; and in rheumatic 
 enlargement of the bursse which has passed into a chronic form, 
 they are almost indispensable for effecting a rapid cure. In 
 both these latter cases their application should be followed by 
 the external use of iodine. The iodine paint, which is often 
 recommended, is not a good form of application, except for the 
 purpose of counter-irritation, inasmuch as it causes desquama- 
 tion of the cuticle, and thus by its caustic action interferes with 
 the absorption of the remedy. A much more serviceable ally 
 1 See Tables, pages 347 350, of this Treatise.
 
 380 CHRONIC RHEUMATISM. 
 
 is to be found in the Compound Iodine or Biniodide of Mercury 
 ointment, or the iodine lotion, the formuhi for which I have 
 given elsewhere.^ 
 
 I have hitherto spoken of liniments and fomentations as 
 applicable only to lumbago and other varieties of muscular 
 rheumatism. But their efficacy is by no means confined to 
 these cases. Nothing proves more serviceable in old-standing, 
 painful affections of the joints, than warm opiate fomentations ; 
 and not unfrequently liniments or embrocations prove equally 
 beneficial. Various prescriptions have been already given, 
 which, in my hands, have proved exceedingly efficacious f but 
 in this particular form of disease, a liniment, composed of a 
 drachm of the essential oil of bitter almonds and fifteen drachms 
 of almond oil, may be used with the greatest benefit. The 
 native oil of laurel, applied externally, was a remedy much in 
 vogue among the North American Indians for the cure of 
 rheumatism and other affections of the joints, and the liniment 
 now recommended possesses all its virtues in a much higher 
 degree. More than once, pains, which had resisted all other 
 remedies, have yielded readily under its soothing influence. 
 
 There is yet another external application well deserving of 
 a trial in muscular rheumatism, which has passed into a chronic 
 state : I mean an ointment containing Aconitine or Veratria. 
 That containing aconitine is far the most powerful and efficient. 
 So long as the disease is at all active in its nature, I have never 
 known benefit derived from its employment ; but its beneficial 
 influence has been so often witnessed when the more urgent 
 symptoms have been subdued, and the remaining pain has 
 appeared to be neuralgic in its nature, that no one can doubt 
 its efficacy in many cases which, under other treatment, prove 
 obstinately intractable. It is highly stimulant and counter- 
 irritant in its action, and excites redness of the skin wherever 
 it is applied, together with a sense of tingling or pricking. But 
 as soon as this has ceased, its effect is sedative ; and, in some 
 instances, the only interval of case which the patient obtains 
 are the few hours which immediately follow its employment. 
 Sometimes, from the situation of the pain, it may be difficult, 
 1 Note, p. 326. ^ Page 374 of this Treatise.
 
 BENEFICIAL EFFECT OF LOCAL REMEDIES. 381 
 
 if not impossible, to make effective use of the ointment, and, in 
 such cases, Fleming's Tincture of Aconite or an alcoholic solu- 
 tion, formed by dissolving from three to four grains of aconi- 
 tine^ in six drachms of rectified spirit and two drachms of 
 Glycerin, and applied to the part by means of a camcl's-hair 
 brush, proves an excellent and efficient substitute. In inter- 
 costal rheumatism aconitine proves remarkably serviceable, and 
 is undoubtedly the most valuable external remedy we possess. 
 When the fleshy parts are principally affected, and the 
 patient is unable, from the nature of his pursuits, to confine 
 himself any longer to the house, it is well to protect the seat of 
 pain from cold, and to maintain a constant action of the skin, 
 by the application of flannel bandages or warm stimulating 
 plasters. In lumbago nothing answers better than a bandage 
 of oiled silk lined with flannel, the Emplastrum Arnicas Mon- 
 tanse,^ and the Burgundy pitch plaster; and if it be considered 
 desirable to inci'ease the stimulating properties of the latter, 
 its surface may be sprinkled with hydrochlorate of ammonia. 
 When the joints, the tendons, the bursae, or the periosteum are 
 aff'ected, the Emplastrum Ammoniaci c. Hydrargyro is gen- 
 erally of greater service, while in some instances in which the 
 joints and tendons are stiff" and thickened, the Emplastrum 
 lodinii,^ spread upon wash-leather, and applied closely round 
 the aff'ected part, exerts a stimulating and softening influence 
 which is not to be attained in any other way. Again, when the 
 irritability of the skin is such as to preclude the use of these 
 stimulating plasters, the Emplastrum Opii may be ordered, or 
 warmth may be preserved by wrapping the part in the finely- 
 carded wool which is known by the title of medicated wool. 
 The rheumatic patient is so apt to suff"er from cold and atmos- 
 pheric vicissitudes, that he should be warmly clad at all times, 
 and not only should the parts most apt to suff'er be more than 
 ordinarily protected, but his whole body should be incased in 
 
 1 The aconitine should be obtained from Morson, of Southampton Row, 
 Bloomsbury. 
 
 2 This plaster is prepared by Twinberrow, of Edward Street, Portman 
 Square. 
 
 3 To be obtained at Ewens's, 106 Jermyn Street, St. James's.
 
 382 CHRONIC RHEUMATISM. 
 
 flannel, or better still in silk, and, in winter, covered with that 
 warm woolen clothing known linder the name of fleecy hosiery. 
 
 Other expedients have been adopted occasionally for the 
 relief of old rheumatic pains, among which I may mention 
 electricity, galvanism, and acupuncturation. In my experience, 
 however, they have been rarely needed, and when needed, have 
 seldom afforded material aid. The former I have seen exten- 
 sively employed, and have sometimes used it at the instance of 
 m}' patients ; but so frequent has been its failure, that in the 
 few cases in which relief has followed its use, I have been in- 
 duced to regard the pain as of nervous origin, or its subsidence 
 coincidently with the use of electricity as a mere coincidence. 
 Galvanism, also, I have generally found useless, if, indeed, it 
 has not aggravated the pain ; but in some few instances of 
 lumbago, and in certain other instances, in which the pain has 
 been stationary, and more or less paroxysmal in its character, 
 I have witnessed such speedy recovery after the employment 
 of the continuous current, that I do not hesitate to recommend 
 its use in obstinate cases of muscular and neuralgic rheumatism. 
 In the synovial form of the disease, I have never known it of 
 the least service. 
 
 Observation has not supplied me with sufiicient data for an 
 opinion as to the efficacy of acupuncturation. On looking over 
 my note-books, I find only five cases in which I have witnessed 
 its application in muscular rheumatism. In four of these it 
 proved utterly useless ; in the fifth some amendment shortly 
 followed its use, but whether as the 'result of its employment, 
 is questionable. Mr. Churchill, however, has reported most 
 favorably on its curative powers;* and Dr. Elliotson, who " has 
 employed it very extensively, both in private and in St. 
 Thomas's Hospital, in rheumatism," entirely confirms Mr. 
 Churehill's opinion, and says, "it is useful chiefly in rheuma- 
 tism of fleshy parts, and the more so as the disease is less 
 inflammatory."^ In France, M. Berlioz^ has tested it largely. 
 
 ' " A Treatise on Acupuacturalion," &c. London, 1828. 
 * " Medico ('liir. Trans.," vol. xiii. 
 
 ' " Meinoiies sur les Maladies Cbroniques, les evacuations sanguines et 
 I'acupuncture." Paris, 1816.
 
 INFLUENCE OF A WARM CLIMATE, ETC. B83 
 
 and speaks most higlily of its virtues ; as does also M. Jules 
 Oloquet, who has recorded the history of 91 cases in which it 
 proved of the greatest service. I am bound, therefore, to 
 admit, that in some cases it may prove eminently useful ; but 
 I am satisfied by experience that its application is disagreeable, 
 that its curative powers are uncertain, and the cases in which 
 it is necessary to call them into requisition so rarely met with 
 as to be quite exceptional. 
 
 When all remedies fail, change of air, if not of climate, with 
 active exercise, judicious bathing, long-continued friction, and 
 constant attention to the state of the skin, will often prove 
 effectual for our patient's relief. So long as the effect of a warm 
 climate is untried, we need never despair of a radical cure. 
 Even when our best-directed efforts have proved fruitless, a few 
 days' sea sickness, followed by the influence of genial warmth, 
 a change of scene, repose of mind, an altered diet, and a new 
 mode of life, not unfrequently prove successful in restoring a 
 hea;lthy state of assimilation, and in stimulating the skin, the 
 kidneys, and other excretory organs to the vigorous exercise 
 of their functions. With the stomach performing its duty 
 properly, the skin acting freely and regularly, and the liver and 
 kidneys fulfilling their office of depurating agents efficiently, 
 the rheumatic poison cannot fail to be eliminated, its further 
 formation checked, and the system invigorated. And when 
 such is the case, the rheumatic pains will not be long before they 
 take their final departure. Many a person who for years had suf- 
 fered from chronic rhcum'atism, has speedily got rid of this in- 
 veterate enemy, by thus having recourse to Nature's assistance 
 in conjunction with the aid of judicious medical treatment.^ 
 
 1 While these sheets were passing throun:h the press, I met with the follow- 
 ing observations of my friend, Dr. Dundas, in his recently published work, 
 entitled " Sketches of Brazil," which I quote in confirmation of the powerful 
 and salutary effect very often produced on the organic functions by a brief 
 residence in a warm climate. Speaking of the salutary influence of the sun, he 
 says: p. 103, " Independently of direct physiological proof, this proposition 
 will be fully admitted by every tropical sojourner, in whom years of subse- 
 quent exhaustion can never entirely efface the recollection of the buoyancy of 
 spirits, unclouded mind, and exquisite appreciation of mere animal existence 
 which, unless counteracted by some special influence, characterize the first 
 years of a tropical life."
 
 CHAPTER XIII. 
 
 ON SCIATICA. AND OTHER FORMS OF NEURALGIC 
 RHEUxMATISM. 
 
 When rheumatism attacks the nerves or their fibrous envel- 
 opes, it causes pain, which follows the course of the nervous 
 trunks, and extends along their several branches. The pain 
 is bounded by such narrow limits, and can be traced so clearly 
 following the track of the larger nerves, that it cannot be mis- 
 taken for pain affecting any of the other structures. It is often 
 someAvliat paroxysmal in its accession, and, though varying in 
 its character in different cases, is usually severe and very obsti- 
 nate in its continuance. Sometimes it is fugitive, and wanders 
 from one extremity to another, but more generally it remains 
 stationary in the part first affected for days, or weeks, or months. 
 It is frequently accompanied by constitutional derangement, 
 and is sometimes attended by fever, but more comnjonly, 
 although the patient is "out of sorts," the pulse, the tongue, 
 and the urine do not deviate greatly from the condition of 
 healtli. 
 
 The most remarkable, as also the most common form of its 
 attack, is that known by the name Sciatica. Emerging from 
 the pelvis beneath the lower border of the pyriformis muscle, 
 the sciatic nerve, formed by branches from the sacral plexus, 
 passes vertically down the back of the thigh to the ham, and 
 thence, under the name of posterior tibial, descends to supply 
 the leg and foot. This is the nerve which, when irritated by 
 disease, excites the distressing pain of sciatica. The pain, like 
 the nerve, commences in the loins, and shoots down the back of 
 the thigh and leg. It is usually aggravated by damp and cold, 
 as also by pressure, and by movement of the limb, and thus it 
 occurs with more than ordinary severity when the patient goes
 
 SCIATICA, NEURALGIC RHEUMATISM, ETC. 385 
 
 up stairs, or attempts to walk after sitting in a cramped posi- 
 tion. In one ease it is of a dull, achirig, or benumbing charac- 
 ter, and wearies by its long continuance rather than by its 
 severity; in another it exhausts, not only by its obstinacy, but 
 by the extreme violence of the startings, accompanied by pains 
 of an excruciating nature, which occur at intervals throughout 
 the attack ; while, in a third class of cases, it prostrates all the 
 energies of mind and body by the continued indescribable tor- 
 ture which it occasions. The limb actually quivers with pain, 
 and the muscles are drawn ■ into knots by cramp, and thus 
 afflicted and unable to move, the unhappy patient lies moaning 
 during the day, and dreading the approach of night, when the 
 violence of the symptoms is, if possible, increasexJ. 
 
 Sciatica is commonly met with about the middle period of 
 life, very few cases occurring before the age of 20, and as few 
 after the age of 60. This will be seen from the subjoined 
 tables,* and although there is no reason why the disease should 
 not occur at a much earlier, or a much more advanced age, I 
 have never chanced to encounter it before the age of 15 nor 
 after the age of 67. Usually confined to one side of the body, 
 it sometimes affects both extremities at the same time, so that 
 in 14 out of 103 examples of the disease, reported by Mons. 
 Valleix, the pain extended to both extremities, Avhile in 46 it 
 was confined to the left side, and in 43 to the right.^ In my 
 own experience the simultaneous affection of both extremities 
 has been much more uncommon, for I have met with it only in 
 five instances, while in 42 cases the pains attacked the right 
 side only, and in 28 invaded the Icft.^ In some other respects 
 
 1 Collection of Cases cited by M. Valleix. Authors Cases. 
 
 Up to 20 years of age. ... 4 1 
 
 From 20 to 30, 22 10 
 
 " 30 to 40, 30 18 
 
 " 40 to .50, 3,5 31 
 
 " 50 to 60, 2G 13 
 
 " 60 to 70, 6 2 
 
 Over 70, 1 
 
 124 75 
 
 ''■ See Valleix, " Traile des Ncvralgies," p. 503. 
 3 These 75 cases were well-marked examples of the disease, and do not in-
 
 386 SCIATICA, AND OTHER FORMS OP 
 
 my observations differ from those of eminent members of our 
 profession, for no less than 61 out of my 75 cases occurred in 
 men, and 14 only in women, whereas Dr. Copland' gives it as 
 his opinion that women are more prone to its attacks than men. 
 In this instance, however, Mons. Valleix's experience coincides 
 with mine, for he found as many as 72 men^ among 124 patients . 
 affected with this disorder. It is probable that my numbers 
 may shoAV a greater disproportion between the frequency of 
 attacks in the two sexes than is warranted by general experi- 
 ence, inasmuch as my cases, with thirteen exceptions, occurred 
 among hospital patients, in whose rank of life the men, from 
 the nature of their occupation, are, much more than the women, 
 exposed to the exciting causes of the disease. Judging, how- 
 ever, from inquiries I have made from various gentlemen in 
 extensive practice, I am inclined to think, that if hysterical 
 affections and painful rheumatism of the muscles of the thigh 
 are excluded from the calculation, the proportion of attacks in 
 the two sexes will be found to approach nearer to my numbers 
 than even to those of Mons. Valleix. 
 
 The disease, as already stated, is apt to prove vei-y obstinate 
 in its continuance. Sometimes it may be subdued by appro- 
 priate treatment in the course of a few days, if proper remedies 
 be given early and pushed vigorously ; but if not removed soon 
 after its invasion, it frequently resists all efforts for its expul- 
 sion, and harasses the patient for weeks or months. Indeed, 
 the limb may never altogether recover from the attack, but may 
 waste, ^nd remain for years, if not for life, atrophied, and more 
 or less weak and paralyzed. Three well-marked instances of this 
 sad result have come under my notice in hospital practice. In 
 one of these cases the attack of sciatica had occurred thirteen 
 years, in another eleven years, and in the other five years before 
 I saw the patient. In truth, sciatica is not itself a disease, but 
 
 elude any other of the painful affections of the hip, or muscles of the thigh, 
 which are often, but wrongly, comprised under the term sciatica. This may 
 possibly account for the discrepancy observed between my figures and the re- 
 corded experience of certain other observers. 
 
 1 See '' Dictionary of Medicine." 
 
 * Loc. cit., p. 5G6.
 
 NEURALGIC RHEUMATISM. 387 
 
 rather is a symptom of many diseases. Thus, in some in- 
 stances, it depends upon organic changes in the nerve itself, 
 or the surrounding structures ; in others, upon mischief in the 
 brain ; in others again, upon nephritic or gastric irritation, or 
 upon irritation of the sacral plexus consequent on an unhealthy 
 loading of the intestines ; while in another large class of cases 
 it is connected with constitutional causes, each one of which 
 produces a different alteration in the condition of the blood, 
 and requires for its removal a different mode of treatment. 
 And as different affections have been thus confounded under 
 the one title of sciatica, the cure in each case is dependent on 
 the accuracy of the physician's diagnosis. A remedy which is 
 suited for the relief of a simple painful affection of the nerve 
 may be useless to a patient who is suffering from rheumatic or 
 gouty irritation, or from inflammation with effusion of lymph 
 and serum into the sheath of the nerve ; while that, again, 
 which in such a case proves beneficial, would probably exert no 
 curative influence when the pain is dependent upon nephritic, 
 gastric, or intestinal irritation, or upon local changes of struc- 
 ture, either in the nerve itself or in the neighboring parts. 
 
 Thus, then, in every case of sciatica, three points should be 
 accurately ascertained before a plan of treatment is decided 
 on: 1st, the actual nature of the disease, whether it really is 
 what it appears to be, viz., a true affection of the sciatic nerve ; 
 2dly, the origin and cause of the disease in the particular 
 instance before us ; 3dly, the extent and character of the mis- 
 chief to be remedied. 
 
 The complaints which are most apt to be mistaken for sciatica, 
 dependent on rheumatic or gouty affection of the nerve, are 
 disease of the hip-joint and nephritic irritation. Neither of 
 these, however, is likely to prove a source of much perplexity, 
 if care be taken in the examination of the symptoms. When 
 the former is present, there certainly may be pain in the affected 
 side, but, unlike the pain of sciatica, it will be increased when 
 the weight of the body is thrown on to the affected limb, as also 
 when the head of the bone is pushed upward against its socket, 
 while the patient is lying on an even surface in a horizontal
 
 388 SCIATICA, AND OTHER FORMS OF 
 
 position. Moreover, after a time the disease is often accompanied 
 bj flucti;ation, more or less perceptible, giving rise to a fullness 
 in the groin, while the constitutional disturbance by which it is 
 attended increases gradually with the progress of the disease. 
 By these symjitoms alone the distinction between the two forms 
 of malady is made sufficiently apparent, but it is rendered still 
 more striking by the fact that, in hip disease, the pain is 
 usually confined to the hip and knee joints, and does not 
 extend to the trunk of the sciatic nerve, and even when it does 
 so, is not aggravated, as in true sciatica, by pressure in the 
 course of that nerve. 
 
 Nephritic irritation displays symptoms equally peculiar and 
 diagnostic. If it sometimes causes spasmodic pain shooting 
 down the thigh on the affected side, just as in a case of sciatica, 
 it at least gives perfectly significant tokens of its true source 
 and nature. It is accompanied by pain in the course of the 
 ureters, and by painful retraction of the testicles, with pain 
 shooting down to the tip of the penis, and a frequent desire to 
 pass water. Moreover, the urine is not the clear, bright urine 
 of ordinary sciatica, but is loaded with lithates, or charged 
 with crystals of lithic acid, or oxalate of lime. Thus it causes 
 many symptoms which sciatica does not, and, equally with hip 
 disease, fails to occasion tenderness on pressure in the course 
 of the sciatic nerve. 
 
 Having clearly ascertained that the disease is indeed sciatica, 
 we must next investigate its source and nature. Is it a true 
 rheumatic affection ? Is it connected Avith a syphilitic taint V 
 Has gout any share in its production ? Is it caused by gastric 
 or intestinal irritation ? Does it appear to be of purely neu- 
 ralgic origin ? Is it symptomatic of mischief in the brain ? or 
 is it dependent on the pressure of some tumor, or on an alter- 
 ation in the nerve itself, whether at its origin or in some part 
 of its course ? These are indeed important questions, as 
 involving the rationale of the treatment to be adopted, and the 
 nature of our prognosis. 
 
 The two last-mentioned causes of the disease may be passed 
 over for the present, as of comparatively rare occurrence, and
 
 NEURALGIC RHEUMATISM. 389 
 
 as being accompanied by other symptoms, which, to the careful 
 observer, can hardly fail to afford some insight into the source 
 and nature of the existing mischief. The others, however, 
 bear so close a relation to the treatment to be pursued in each 
 particular instance, that it may be well to examine more in 
 detail the symptoms by which the operation of each is denoted. 
 Thus, then, if the patient is thin, pale, sallow, and extremely 
 sensitive to atmospheric vicissitudes ; if he has experienced pain, 
 or threatenings of pain, in other parts of the body ; if, at some 
 former period, he has suffered from rheumatism affecting the 
 joints ; and, above all, if hi^ present attack is the result of 
 exposure to cold and damp, the disease under which he is 
 laboring is rheumatic, and is to be relieved by vapor baths, 
 guaiacum, alkalies, and similar remedies. On the other hand, 
 is he stout, florid, and a free liver, taking little exercise, and 
 sleeping much, is he plagued with heartburn, acid eructations, 
 and occasional lowness of spirits, or has he previously suffered 
 from gout, his malady is certainly of gouty origin, and is to be 
 cured by colcliicum, alkalies, and alteratives. Again, is he 
 cachectic, and out of health ; has his throat been ulcerated, or 
 his skin disfigured by blotches or eruptions ; has he taken mer- 
 cury, or experienced pains in his bones, the mischief is prob- 
 ably due to a syphilitic taint, and is to be cured by sarsaparilla 
 with iodide of potassium. Or again, is he robust, and usually 
 in the enjoyment of excellent health ; has his present attack 
 been preceded by constipation or irregularity of the bowels, by 
 flatulent distention, and crampy pain in the abdomen ; and, 
 above all, is it accompanied by coating of the tongue and fetor 
 of the breath, then, if the disease does not acknowledge either 
 of the origins .before alluded to, it is. probably due to irritation 
 of the sacral plexus of nerves consequent on an unhealthy load- 
 ing of the intestines. This opinion will be confirmed, if the 
 pain be confined to the right leg, for the disease not unfre- 
 quently arises from unhealthy accumulation of fajcal matter in 
 the caput coli. Such a case as this is to be cured by the 
 administration of active purgatives, both in the form of enema 
 and by the mouth, together with such other medicines as are
 
 390 SCIATICA, AND OTHER FORMS OP 
 
 calculated to carry off the irritating matter, and to produce a 
 more healthy secretion from the bowels. On several occasions 
 I have known patients cured by the administration, on three 
 successive nights, of two grains of calomel, two of extract of 
 aloes, and six of scammony, followed on the morning of the 
 fourth day by an enema, containing an ounce of castor oil, and 
 an ounce of spirits of turpentine, or two drachms of assafetida, 
 -or an equal quantity of the confection of rue. In many of 
 these cases, the action of Croton oil, as recommended by Mr. 
 Hancock, is often of the greatest service. Again, if the patient 
 has never experienced an attack of gout or rheumatism, and 
 has not suffered from wandering pain in the limbs ; if he is free 
 from venereal taint, and has not been subjected to a course of 
 mercury ; if his bowels have been acting regularly, and the 
 dejections are of a healthy character ; if his skin is healthy, 
 his tongue clean, his urine clear, the pulse normal, and the 
 appetite and digestion good ; if, in short, there is an absence 
 of those symptoms which indicate either of the forms of 
 derangement hitherto alluded to, his malady is probably of 
 neuralgic origin, and is to be relieved by tonics, sedatives, and 
 other remedies directed against that variety of derangement. 
 On this point our diagnosis will be greatly strengthened if the 
 urine, when examined under the microscope, is found to be 
 loaded with the octohedral crystals of oxalate of lime. 
 
 Thus, then, according as one or other of these causes may 
 appear to have caused our patient's sufferings, the nature and 
 activity of the treatment must be varied. But that is not all. 
 In true sciatica, from whatever cause arising, very different 
 local changes may be induced, and very different remedies re- 
 quired for their relief. Be the affection rhcumjvtic or gouty in 
 its nature, or be it due to syphilis, or to a distended colon, the 
 pain in either case is referable to a cause of irritation, which 
 may either give rise to no perceptible local change, or may be 
 accompanied by lesions of a more or less serious nature — from 
 simple congestion on the one hand, to copious effusion of serum, 
 or of serum mixed with lymph, within the sheath of the nerve.
 
 NEURALGIC RHEUMATISM. 391 
 
 or to thickening of the sheath itself, on the other.' In 
 the former case, the means already mentioned as adapted to the 
 removal of the several causes from which the affection derives 
 its origin will be sufficient to effect a cure. But, in the latter, 
 the disease is more complex and less tractable. The local con- 
 gestion can seldom be relieved without the aid of local rem- 
 edies, and when the stage of simple congestion is passed, and 
 thickenins: of the sheath of the nerve has occurred, or effusion 
 has commenced within it, the use of topical applications be- 
 comes more than ever necessary. The effusion here is not, as 
 in ordinary rheumatism, of secondary importance ; it gives rise 
 to pressure upon the nerve, impairs its function, and thus leads 
 to malnutrition and wasting of the limb ; and if it be not 
 speedily removed, irremediable alteration of structure takes 
 place, and the nerve, hardened by long-continued pressure, is 
 found after death gray and shrunken. 
 
 In every case of sciatica, then, the existence or non-existence 
 of effusion within the sheath of the nerve, or of thickening of 
 the sheath itself, is a question of primary importance. If no 
 such mischief exists, the remedies before alhuled to, as best 
 calculated to remove the different causes of irritation, will be 
 the most efficient in removing the irritation, with the pain and 
 other symptoms consequent thereon ; whereas if effusion or 
 thickening has already taken place, measures will be needed 
 not only to allay existing irritation, and remove its cause, but 
 to promote absorption of the effused fluid, and remedy the local 
 mischief which has occurred. 
 
 By what symptoms, then, are we assured of the existence of 
 effusion or of pressure on the nerve ? I know not whether the 
 
 1 See •' Cotunniu3 de Ischiade Nervosa Commentsirius," cap. xxxv, and Gen- 
 drin's " Histoire Anatomique de rinflammation." The death of a patient dur- 
 ing the existence of acute sciatica is so extremely rare, and the pathological 
 effects of simple irritation and congestion — the sole effects, I believe, of most 
 attacks of sciatica— pass off so rapidly, that there are few instances on record 
 in which any lesion of the nerve has been discovered after death This fact, 
 however, affords no argument against the presumption, which is countenanced 
 by strict physiological reasoning, that when irritation and congestion pass on 
 to inflammation, the ordinary results of such action, namely, the effusion of 
 lymph and serum, will occur at the part affected.
 
 392 SCIATICA, AND OTHER FORMS OF 
 
 experience of others corresponds with my own observations on 
 this subject, but such signal benefit has been often derived from 
 remedies applied in accordance with the views I am about to 
 enunciate, that I cannot but think them entitled to considera- 
 tion. 
 
 At the commencement of an attack, no certainty can be felt 
 as to the existence of pressure on the nerve. But the proba- 
 bility of its occurrence in the course of the disease is in pro- 
 portion to the severity of the local symptoms and the intensity 
 of the febrile disturbance, and remedies should be selected and 
 apportioned accordingly. If pain be the prominent feature of 
 the attack, and be unaccompanied by febrile symptoms, it 
 would be right to act as though no thickening or effusion, had 
 taken place ; whereas, if the pain be attended by fever, it 
 would be prudent to have recourse to measures calculated to 
 check those actions on which the occurrence of local mischief 
 depends. But after the disease has lasted longer and has 
 passed into a chronic form, we have more to guide us to a cor- 
 rect diagnosis. If thickening or effusion be present, there is 
 then not only local pain, but numbness and partial paralysis of 
 the limb as the natural and characteristic results of pressure on 
 the nerve. The nerve being compressed, its function is im- 
 paired, and the symptoms alluded to necessarily ensue. Hence, 
 when a patient who is suffering from sciatica complains of a 
 dull, aching, and benumbing pain in the limb, causing it to feel 
 swollen, when this sense of numbness and increased bulk has 
 succeeded to pain of greater intensity, accompanied by cramps 
 and startings of the limb ; and when, more especially, in addi- 
 tion to these symptoms, there is more or less inability to move 
 the limb,' — inability arising from loss of power, and not as a 
 
 1 In the cases alluded to, it will be found that the patients are unable to 
 move the limb freely, even though the pain be not very severe ; they complaia 
 that the Jimb is weak, and feels very heavy, and that there/ore they cannot 
 move it readily : nay, more, they will often remark, that they have not as 
 much power over it as they previously had, when the pain was much more 
 severe. Though the first activity of the inflammation be subdued, the effused 
 matters which result from that inflammation produce pressure on the uerve, 
 impair its function, and thus lead to loss of power in the limb.
 
 NEUHAL(iIC RHEUMATISM. 393 
 
 result of excessive pain, — pressure on the nerve may be infer- 
 red, and steps should be taken to eflfcct its removal either by 
 mechanical or medicinal means. In such cases I have repeat- 
 edly seen sedatives employed freely and pertinaciously, and 
 various antisciatica remedies made use of with the view of ef- 
 fecting a cure ; but until the measures alluded to have been 
 adopted, the failure has been so uniform and so complete, that 
 now, whenever symptoms of pressure present themselves, I al- 
 ways resort to that method of treatment which, whatever its 
 modus operandi, is entitled to the credit of giving speedy 
 relief. 
 
 The measures which prove most eflBcacious in checking the 
 progress of the local mischief, and promoting absorption of the 
 matters effused, are cupping, leeching, and blistering, combined 
 with the internal administration of mercury, iodide of potas- 
 sium, and diuretics. The practice of cupping, leeching, and 
 blistering, for the relief of sciatica, was first introduced by 
 Cotunnius, a celebrated Neapolitan physician,^ under the idea 
 of evacuating an acrid humor from the sheath of the nerve ; 
 and the comparative disuse into which it has fallen has re- 
 sulted, I believe, from its having been at one time recklessly 
 employed. It has been often resorted to without reference to 
 the question whether the symptoms denoted pressure on the 
 nerve, and the possibility therefore of there being fluid within 
 the sheath of the nerve, or thickening of the sheath itself; and 
 even in cases attended by symptoms indicative of pressure, its 
 good effects have been counteracted by unrestrained movement 
 of the limb, and by the exhibition of stimulant and tonic med- 
 icines, instead of mercury, iodide of potassium, and other med- 
 icines having a tendency to promote the absorption of the ef- 
 fused fluid. Moreover, it was formerly the practice to make 
 use of issues, rather than of blistering; and as their only ef- 
 fect was, as Dr. Seymour remarks, " to add additional distress 
 to unrelieved pain," it is not surprising that discredit should 
 have been thrown on this whole system of treatment. Em- 
 ployed, however, with judicious discrimination, no remedies are 
 
 1 " Cotunnius de Iscliiade Nervosa Comnieutahus." 8vo, Vienna), 1770. 
 26
 
 394 SCIATICA, AND OTHER FORMS OF 
 
 capable of affording greater relief. When from the activity of 
 the febrile disturbance, the severity of the pain, and the senvse 
 of local heat which attends it, it is probable that the local mis- 
 chief is of recent date, even if it be not still going on, then 
 cupping or leeching, followed by blisters in the course of the 
 nerve, together with mercurials and purgative and cooling diu- 
 retic medicines, should be resorted to early and vigorously.^ 
 On the other hand, when all febrile symptoms have passed 
 away, when the local mischief is of some standing, and is prob- 
 ably due to causes no longer in existence, then mercurial action 
 should be slowly induced ; and blisters should be used in pref- 
 erence to, if not to the exclusion of, cupping and leeching. In- 
 deed, in such cases, vesication is, of all local remedies, the most 
 important, and should be steadily persevered in, the blisters 
 being long and narrow, placed along the track of the nerve, 
 and the blistered surface dressed with mercurial ointment, or 
 sprinkled daily with powdered morphia, to relieve the pain. In 
 some instances, however, morphia applied in this manner ap- 
 pears to aggravate rather than to allay the pain; and when 
 such is the case, its use should be discontinued. 
 
 There is one local application of singular efficacy in the cure 
 of sciatica connected with pressure upon the nerve ; I mean that 
 known as acupuncturation. Its virtue is supposed to depend 
 upon the mechanical assistance it affords toward the evacua- 
 tion of fluid from the sheath of the nerve. While the patient 
 is lying flat on his stomach, six or eight pairs of needles, spe- 
 cially adapted for the purpose, are carefully inserted into the 
 thigh along the course of the sciatic nerve, the object being to 
 puncture the neurilemma, and thus to allow of the escape of 
 any fluid. The operation, if conducted slowly, causes little pain 
 or inconvenience, is altogether.devoid of danger, and deserves 
 a trial in obstinate cases. On three occasions I have seen it 
 afford immediate relief, and in one instance the relief was com- 
 plete and permanent. In many others, however, it has proved 
 unsuccessful : and observation has led me to believe, that the 
 • difference in the result has been attributable, in some instances, 
 1 See Case II, appended to this chapter.
 
 NEURALGIC RHEUMATISM. 395 
 
 to imperfect manipulation, whereby the sheath of the nerve has 
 escaped unpunctured, and in some, to the widely differing cir- 
 cumstances under which the operation has been undertaken. 
 If resorted to when no effusion exists, or while any trace of 
 inflammation remains, it cannot be useful, and is found not to 
 be so in practice.^ Indeed, in the latter case, it often acta 
 prejudicially ; whereas, if employed when inflammation has 
 subsided, and the nerve is irritated by the unwonted pressure 
 of the effused fluid, it promises speedy and effectual relief. 
 
 It is not to be supposed,- however, that in all cases of scia- 
 tica, or indeed in the major part of them, effusion takes place 
 into the sheath of the nerve. The symptoms by which that 
 lesion is accompanied are very striking, and by no means of 
 common occurrence. In most instances of sciatica the pain is 
 obviously unconnected with pressure on the nerve, and arises 
 either from its sympathy with irritation in the intestinal canal 
 or some other distant part of the body, or else from irritation 
 and congestion of the nerve itself consequent on the presence 
 of some morbid matter in the blood. In the former cases the 
 cause of irritation must be removed before any alleviation of 
 pain can be expected ; in the latter, counter-irritation and seda- 
 tives, combined with such medicines as will neutralize or elim- 
 inate the peccant matter, will generally afford relief. But in 
 neither will acupuncturation or the remedies already spoken of 
 as calculated to produce absorption, have the slightest influence 
 on the progress of the disease. 
 
 Of all internal remedies, those which come most generally 
 and most beneficially to our aid are sedatives, with opium and 
 belladonna at their head. Opium, with the various salts of 
 morphia; belladonna, given internally and applied externally, — 
 henbane, conium and stramonium, the cannabis indica, digitalis, 
 aconite and veratria, these are among the most powerful and 
 most efl^icient of our allies. In purely neuralgic cases they 
 appear to act as directly curative agents, and require little aid 
 
 1 In this statement I am borne out by Dr. EUiotson, who says, " I have never 
 seen it beneficial in any inflammation or inflammatory pain." (" iMedico-Chir. 
 Trans.")
 
 396 SCIATICA, AND OTHER FORMS OF 
 
 in effecting our object, while even in other forms of sciatica 
 they prove most valuable in mitigating the severity of the pain. 
 But in true rheumatic or gouty cases this class of remedies, 
 with the exception, perhaps, of aconite, veratria, and digitalis, 
 appears to be of service only in so far as they tend to diminish 
 nervous irritability, and procure repose. Their value seems to 
 depend upon their power of temporarily assuaging pain and 
 producing sleep, more than upon the exercise of any curative 
 influence. They put a stop to that irritability which would 
 otherwise render futile all efforts to improve the general health 
 of our patient, and to prevent the further generation of the 
 rheumatic poison ; and, moreover, after the cause of the disease 
 has been got rid of, they enable the patient to endure its painful 
 consequences during the period required for their removal. 
 
 Two points, therefore, present themselves for consideration 
 before commencing the administration of this class of medicines ; 
 first, what sedative is likely to prove most beneficial in the 
 particular instance before us ? and, secondly, in what doses 
 will it be needed ? To neither of these questions can a definite 
 answer be returned. The particular sedative to be employed 
 must be regulated in part by the idiosyncrasy of the patient, 
 by the form which the disease has assumed, and by the stage 
 at which it has arrived ; and the quantity of the sedative 
 required can only be measured by the influence exerted over 
 the intensity of the pain. In many cases opium and the salts 
 of morphia afford us all the assistance we desire ; but in some 
 they disagree, or unless administered in very large quantities, 
 arc practically inoperative for good. It then becomes expe- 
 dient to have recourse to some other substances of the same 
 class, and belladonna, stramonium, hyoscyamus, coniura, or the 
 cannabis indica, may be employed as occasion requires. Bella- 
 donna is especially useful in those cases which are marked by 
 spasmodic twitchings of the muscles, whether manifested by 
 cramp, or by starting of the limb ; and from a quarter to a 
 third, or even two-thirds of a grain of the extract may be safely 
 administered twice or three times a day. It is apt, however, 
 to produce dryness of the fauces, together with vertigo, and
 
 NEURALGIC RHEUMATISM. 397 
 
 excessive depression of the vital powers. It should, therefore, 
 be employed with extreme caution, the patient being watched 
 throuo^hout the period of its administration in order that, at the 
 least dilatation of the pupil, or at the occurrence of headache 
 with confusion of thought, the use of the remedy may be at once 
 abandoned. 
 
 But it is not only from its internal administration that benefit 
 may be obtained in these cases ; the greatest advantage is some- 
 times derived from its direct application to the seat of pain, 
 both in the form of plaster and in that of fomentation. Not 
 unfrequently an admixture of belladonna and opium may be 
 advantageously prescribed, in the proportion of one drachm of 
 the extract of belladonna to an ounce of laudanum and three 
 drachms of glycerin. A piece of lint wetted with this mixture, 
 and covered with oiled silk, often affords very great relief when 
 placed along the course of the nerve. But in whatever form 
 the remedy is applied, it certainly exerts a remarkable influence 
 over the violence and duration of the spasms ; and the only 
 point to be borne in mind is, that it must not be used, even in 
 the endermic method, without much caution. For if an over- 
 large quantity be employed, or a slight abrasion exist in the 
 cuticle, so that absorption takes place rapidly, it is apt to pro- 
 duce excessive dryness of the fauces, with giddiness, dimness 
 of vision, and other early symptoms of narcotic poisoning. 
 
 Stramonium, which was first recommended by the late Dr. 
 Marcet, has been employed largely in the cure of this disease, 
 but not, as far as my experience has gone, with any great suc- 
 cess. In some cases, where the symptoms shift from limb to 
 limb, and probably are more strictly nervous than rheumatic, 
 the extract produces a decidedly good effect ; but in no single 
 instance in which the disease has been obstinately stationary, 
 have I known it exercise any control over the violence or 
 duration of the symptoms. Administered in doses of from one 
 to two grains, its operation is sometimes remarkably sedative, 
 but more generally its action is uncertain, and is accompanied 
 now and then by excessive dryness of the throat and fauces. 
 
 The hyoscyamus' niger and the conium maculatum yield
 
 398 SCIATICA, AND OTHER FORMS OF 
 
 tinctures and extracts possessing sedative qualities well adapted 
 for the relief of this painful disease, but not possessing, as far 
 as I am aware, any obvious superiority over those already 
 described. They are certainly milder and more manageable 
 medicines ; and as they are often tolerated by the system when 
 opium and belladonna disagree, they may, and do sometimes, 
 prove serviceable. But in proportion as they are milder than 
 the aforesaid anodynes, so also, in most instances, they are 
 inferior in allaying pain and calming the irritation consequent 
 thereon, and their use, therefore, should be reserved for those 
 cases in which there is something to contraindicate the employ- 
 ment of those which are more powerful and more efficient. 
 
 The cannabis indica may be administered in the form either 
 of extract or tincture, but the latter has appeared to me the 
 most speedy and certain in its operation. Given in doses of 
 from twelve to twenty minims, it has often allayed pain and 
 produced repose after most of the ordinary sedatives have 
 failed. Its action, however, is rather capricious. In some 
 instances it proves anodyne and narcotic in the highest degree ; 
 in others its action, though marked by relief from pain, is not 
 accompanied by true sleep, but rather by a happy semi-con- 
 scious dreamy state ; while in others, again, it fails entirely in 
 exercising any anodyne influence, and is apt to stimulate and 
 produce an effect resembling the excitement of intoxication. In 
 one patient who by mistake took double the dose I had ordered 
 this effect was most remarkable and distressing. Much caution 
 therefore must be observed in selecting proper cases for its 
 exhibition, and on no pretext should a full dose be given until 
 the patient's susceptibility to its influence has been thoroughly 
 gauged. 
 
 There is one mode of employing morphia and other narcotics 
 which deserves special notice, as enabling us to afford imme- 
 diate, though too often temporary, relief from suffering. I 
 allude to the injection of a concentrated solution of the drug 
 into the cellular tissue of the body. Formerly this practice was 
 unsatisfactory in its results, in consequence of the clumsiness 
 of the means employed ; but, of late years, the improvement in
 
 NEURALGIC RHEUMATISM. 399 
 
 surgical appliances has led to its revival. Indeed, as now em- 
 ployed, it promises to be of great utility. A small glass syringe, 
 with a fine perforated needl^like nozzle, has been manufac- 
 tured, which renders the injection of the solution easy, and 
 almost painless, while at the same time the operator is enabled 
 to calculate to a nicety the amount of fluid injected.^ 
 
 At St. George's Hospital this method of treatment has been 
 had recourse to in a considerable number of cases, and with 
 tolerably satisfactory results. If the disease has not been 
 cured through its agency, the pain at least has been relieved, 
 and temporary repose obtained. In every instance, as far as 
 I am aware, morphia has been the drug made use of; and 
 usually its full effect has been produced, and sleep has resulted, 
 within ten minutes from the first commencement of the injec- 
 tion. Nay more, on several occasions, the repetition of the 
 operation on three or four successive days has been followed 
 by complete and permanent cessation of pain.^ In many 
 instances, however, this has not been the case ; and my impres- 
 sion is, that although the palliative effects of this treatment 
 may be produced in all cases of sciatica, yet that sedative 
 injections do not exercise a curative effect, except in cases 
 where the pain is of a purely neuralgic character, unconnected 
 with local organic lesion, or Avith irritation in distant parts of 
 the body. In short, their curative effects are manifest in the 
 same class of cases as are benefited by morphia, applied to a 
 blistered surface as before recommended.^ The great advant- 
 age which the injection of morphia possesses over the applica- 
 tion of the dru2 to a surface denuded of cuticle is the 
 painlessness of its application, and the speediness of its action : 
 the disadvantage is the power and consequent danger of the 
 remedy when thus administered. The full dose is absorbed, 
 and produces its narcotic effect at once ; whereas, when taken 
 into the stomach, it is mixed with the various ingesta, finds its 
 
 1 This instrument is manufactured by Messrs. Whiclier and Blaise, of tit. 
 James's Street, S. W. 
 
 2 See Case VI appended to this chapter. 
 5 At p. 394 of this treatise.
 
 400 SCIATICA, AND OTHER FORMS OF 
 
 ■way into the veins by slow degrees, and, probably, is in part 
 decomposed in the stomach, and in part carried out of the 
 system by the bowels, without hiving entered the circulation. 
 Be this as it may, the effects of its injection are so powerful and 
 so speedily pro<luced, that I would earnestly counsel those who 
 have recourse to its assistance, not to inject above a quarter or 
 half a grain in the first instance, and to allow at least six hours 
 to elapse before the operation is repeated. I have never 
 known, nor have I ever heard, of mischief being produced by 
 the remedy when thus cautiously employed, and I have seen it 
 produce effects as satisfactory as they were astounding. The 
 agonized sufferer, who for many days and nights in succession 
 has been unable to close his eyes, or obtain a moment of repose, 
 notwithstanding the internal administration of morphia in large 
 doses, has fallen into a calm sleep within a few minutes after 
 the injection has been commenced. 
 
 Dr. Alexander Wood, of Edinburgh, recommends' that an 
 examination be made to ascertain the spot at which the pain 
 is felt most acutely, and that the sedative be always injected 
 at the painful spot. But our experience at St. George's Hos- 
 pital is opposed to this plan of proceeding, inasmuch as it ap- 
 pears that the frequent introduction of a perforated needle, and 
 the injection of fluid at the same spot, is apt to lead to inflam- 
 mation and the formation of abscess — a result which may be 
 avoided if the needle is introduced on each occasion into a dif- 
 ferent part of the affected limb. Moreover, there is not any 
 practical reason why the injection should be performed at the 
 most painful spot ; for our late house-surgeon, Mr. Hunter, who, 
 in the wards of St. George's Hospital, was one of the first in 
 London to carry out the principle of Dr. Wood's practice, 
 ascertained distinctly that it matters not, in the slightest de- 
 gree, at what part of the body the injection is effected. The 
 only requisites for obtaining s.afe and satisfactory results are : 
 1st, that a proper instrument be employed ; 2d, that a concen- 
 trated solution of morphia be used, so that the cellular tissue 
 be not unduly disturbed by the injection of a large quantity of 
 ' See "Assoc. Journ.," Aug. 28, 1858.
 
 NEURALGIC RIIEUxMATISM. 401 
 
 fluid ;' 3d, that the dose be sufficiently large to give relief from 
 suffering, but not large enough to produce toxical effects ; and 
 4th, that the injection be not repeated at the same spot. With 
 these precautions, the remedy is one which may be resorted to 
 advantageously^ whenever the pain of sciatica is very acute and 
 persistent, and resists the action of drugs as ordinarily em- 
 ployed. 
 
 Digitalis is a remedy almost unknown to the profession^ as 
 exercising a curative influence on this disease, but is one, never- 
 theless, on which much reliance may be placed when the pain 
 is intermittent, and purely of a neuralgic character. Sedative 
 and diuretic in its action, it calms the vascular system and 
 excites an increased flow of urine, and thus, though not exer- 
 cising a narcotic influence, it frequently allays pain and affords 
 repose. But its curative effects are only displayed in the class 
 of cases above alluded to. If the system be charged with the 
 rheumatic, gouty, or syphilitic poison ; or if the pain be con- 
 nected with local inflammation, or with costive bowels and intes- 
 tinal irritation, digitalis will be found of little or no avail. In 
 appropriate cases, however, a grain or a grain and a half of the 
 powdered leaves, or from ten to twenty minims of the tincture, 
 repeated three or four times a day, will be found a very valu- 
 able remedy. 
 
 The veratrum album is another remedy which has been em- 
 ployed in certain forms of sciatica. Closely related to the 
 colchicum autuninale, it was recommended by Mr. Moorc^ as 
 long ago as 1811, as a substitute for the celebrated Eau Mddi- 
 cinale of the Chevalier D'Husson. Since that time it has been 
 administered occasionally in every species of gouty or rheumatic 
 affection in which colchicum is ever used, and has been specially 
 
 1 The solution usually employed at St. George's contains ten grains of the 
 Acetate of Morphia to one drachm of distilled water; but I prefer a solution of 
 five grains to the drachm, inasmuch as the salt is more readily soluble in this 
 proportion, while the quantity of the liquid which it is requisite to inject is 
 not large enough to excite local irritation. 
 
 * The only notice I can find of the antineuralgic property of digitalis i« con- 
 tained inrfi brief communication from Mr. Hardwicke, of Rotherham, inserted 
 in the 'Assoc. Med. Journal" for June 1, 1855. 
 
 ^ See "Two Letters to Dr. Jones."
 
 402 SCIATICA, AND OTHER FORMS OF 
 
 recommended in the neuralgic forms of the disease. Given 
 internally in small and repeated doses, it is said to excite cuta- 
 neous exhalation, to increase the action of the kidneys, and to 
 promote secretion from all the mucous surfaces. Of its inter- 
 nal administration, however, I have had a ver^ limited expe- 
 rience, having watched its effects only in some few cases in 
 hospital practice, and, up to the present time, my observation 
 has not led me to form a very favorable estimate of its virtues. 
 Whether owing to imperfection in the preparation employed, 
 or to some other cause which may influence its operation, the 
 effects which have been attributed to it have not ensued. In 
 one or two instances some improvement has taken place after 
 a dose of from five to fifteen minims of the Tinctura Veratri, 
 administered two or three times a day. But more generally 
 the disease has progressed uninfluenced by its action, and it 
 has appeared to me questionable Avhether the improvement 
 which took place in the cases alluded to was really attributable 
 to the agency of the remedy. I have no experience of the 
 internal administration of the alkaloid veratria, but it has been 
 given internally by Sir James Bardsley, who says it possesses 
 "no particular claims to the attention of the profession." 
 
 The preparations of the Aconitum Napellus, whether taken 
 internally or employed externally, arc much mjre efficient 
 remedies in sciatica. I have already^ pointed out the class of 
 cases in which I have found aconite most serviceable, and I 
 may add, that although the extract has been recommended as 
 a convenient form for its administration, I have invariably pre- 
 scribed the tincture, under the belief that it is not only more 
 certain in its action, but is a safer form for the exhibition of 
 the remedy. During the last eight years I have tested its value 
 in twenty-five well-marked cases of sciatica, of which nine were 
 characterized by symptoms of active disease, and sixteen were 
 examples of the disease in its chronic or subacute form. In 
 one only of the first-named class of cases did it appear to exer 
 cise the slightest control over the symptoms, but in five of the 
 chronic cases it afforded almost immediate relief, and "the pa- 
 
 1 See p. 371.
 
 NEURALGIC RHEUMATISM. 403 
 
 tients recovered perfectly under its continued use, wliile in 
 severiil others decided improvement followed its administration. 
 In no single instance did the slightest inconvenience result from 
 its action, and, therefore, I think we are justified in concluding, 
 not onl)' that it proves a valuable and eflScient remedy in many 
 obstinate forms of the disease, but that, if properly adminis- 
 tered^ and carefully watched, it is as safe and manageable as 
 any other medicine. The risk, however, incurred by the care- 
 less exhibition of aconite and veratria is on all hands admitted 
 to be so considerable, that I never have recourse to their inter- 
 nal administration unless I have frequent opportunities of seeing 
 the patient. Externally they may be employed more frequently, 
 as in this form no risk is incurred, and their beneficial influence 
 is often strikingly displayed. More than once the tincture of 
 the roots, or an acidulated solution of the alcoholic extract,^ or 
 alcoholic solutions of the alkaloids aconitine and veratria, ap- 
 plied by means of a camel's-hair brush,^or ointments containing 
 aconitina and veratria,* rubbed night and morning along the 
 course of the affected nerve, have afforded relief after every 
 other remedy had been tried in vain ; and in no single instance 
 within my experience have they given rise to the slightest in- 
 convenience. Very different results, however, have attended 
 their use in different cases. On no occasion in which they have 
 
 1 See p. 372. 
 
 2 The alcoholic extract of aconite, to be obtained at Bell's, in Oxford street, 
 is an excellent preparation. It is far cheaper than pure aconitine; and in the 
 proportion of from ten to twenty grains to an ounce of spirits, slightly acidu- 
 lated with sulphuric acid, it is, I believe, almost as efficacious. 
 
 5 The formula} I usually employ are, for the alcoholic solutions: 
 
 Aconitinae, gr. vj ; Or, Veralria;, gr. xx-xxx. 
 
 Spir. Redificati, 5^j j 
 
 (jtlycerini, 3ij- Misce. 
 These alkaloids should be obtained at Morsou's, of Southampton Row, 
 Bloomsbury. Care must be taken not to employ them where the skin is 
 abraded. 
 
 * For the ointments: 
 
 Aconitina;, gr. x-xv; Or, Veratria;, gr. xxxvj. 
 
 Adipis preparatae, "^v'l] ; 
 
 Olei Oliva;, 3j ; 
 
 Olei Bergamotti, Tl^x ; 
 
 Olei Sautalie, TTl^ij. Misce.
 
 404 SCIATICA, AND OTHER FORMS OF 
 
 been tried during the active or inflammatory stage of the disease, 
 have they exercised the slightest influence for good ; nor have 1 
 seen much benefit result from their employment so long as the 
 patient has exhibited other symptoms of gout or rheumatism; 
 but in obstinate neuralgic cases, unattended by febrile disturb- 
 ance, their curative power has been exerted very conspicuously. 
 
 There is no class of remedies about the efficacy of which, in 
 the cure of sciatica, a greater difference of opinion exists than 
 about counter-irritants. Dr. Macculloch^ and others consider 
 blisters positively injurious when applied directly to the painful 
 part, while a large proportion of the profession in this country 
 and on the Continent regard them as among the most valuable 
 of remedial agents. The truth appears to be, that in propor- 
 tion as the complaint is purely neuralgic, arising from irritation 
 at a distance from the seat of pain, and is independent of local 
 congestion, so are blisters and counter-irritants of less and less 
 value, and that their efficacy becomes apparent only when there 
 exists some local mischief which their action modifies or sub- 
 dues. Whatever may be urged against the indiscriminate use 
 of blisters, there cannot be a doubt that when, in proper cases, 
 a number of them are applied in succession, whether in strips 
 along the whole course of the nerve, or at those points only 
 which are painful on pressure, as recommended by M. Valleix,^ 
 the effect produced is often satisfactory. The pain is not only 
 temporarily relieved, but the disease is permanently arrested. 
 The application of blisters, however, is at all times a painful 
 and disagreeable proceeding : and in sciatica at least, though 
 sometimes successful, is at best a very uncertain remedy. 
 Therefore, as we possess many other means of counter-irrita- 
 tion of almost equal efficacy, and far less painful in their appli- 
 cation, I rarely have recourse to vesication by the Spanish fly, 
 when my object is simply to produce counter-irritation. 
 
 Some persons, however, have not hesitated to employ reme- 
 dies of a still more painful and heroic nature. Thus, the actual 
 cautery, first recommended by Paulus iEgineta, and employed 
 
 1 " Ou Marsh Fever and Neuralgia." 
 
 2 " Traite des Neuralsries."
 
 NEURALGIC RHEUMATISM. 405 
 
 in several instances by Cotunnius, has been resorted to of late 
 years by several practitioners on the Continent. M. Jobert 
 especially, by his practice at the H6pital Saint-Louis, has given 
 his sanction to the use of the red-hot iron, after the manner 
 recommended by Dr. Day, in his notes on the so-called thermic 
 treatment. Whatever the relief aflforded by its application, the 
 remedy is so painful and so fearfully alarming, that I question 
 whether any circumstances would induce me to recommend it. 
 
 Moxas are another form of local application highly spoken 
 of, and not unfrequently used in obstinate cases ; but, as M. 
 Valleix^ very shrewdly remarks, their action is much the same 
 as that of blisters and the actual cautery, but is far more pain- 
 ful than the one, and slower and less efficacious than the 
 other. 
 
 One of the readiest and most efficient methods of applying 
 counter-irritation is by means of a small^^iron, heated by hot 
 water after the manner described at p. 375. It possesses this 
 advantage over every other local remedy, that its action is 
 immediate, and can be regulated so as to produce slight rube- 
 faction of the part, or to raise the cuticle in vesication. But 
 when it is desired to pass beyond the bounds of mere rubefac- 
 tion, nothing proves more efficacious than the strong Liquor 
 Ammoniae, ap])lied on a pledget of lint or a bit of cotton-wool, 
 and covered with a glass. Rubefaction is almost instantly 
 produced, and in a few seconds a blister will be raised. By 
 this means I have known relief afforded on two occasions after 
 several other counter-irritants had failed. 
 
 The tartar emetic ointment, an ointment containing croton 
 oil, or the biniodide of mercury in the proportion of two scru- 
 ples or a drachm to an ounce of lard,^ and various stimulating 
 liniments^ have been employed as counter-irritants in these 
 cases, and have been praised as possessing extraordinary effi- 
 cacy. But the obstinacy and excessive pain and discomfort of 
 the cutaneous eruption they occasion is more than sufficient 
 
 1 Loc. cit., p. 625. 
 
 2 " Cast's of Tic Doloreux," by John Scott. 
 
 * See Paper by Mr. Pearson, " Medico-Ghir. Trans./' vol. viii.
 
 406 SCIATICA, AND OTHER FORMS OF 
 
 to counterbalance their virtues ; and as it docs not appear 
 from the recorded cases that they possess a curative power 
 superior to many other counter-irritants, I consider that their 
 use should not be resorted to except in extreme cases, and 
 when other remedies have failed. 
 
 Various other external applications have been tried for the re- 
 lief of this painful malady. Thus galvanism and electricity have 
 each had their advocates, and by some have been lauded as 
 much too extravagantly as they have been too indiscriminately 
 abused by others. The fact appears to be, that when the dis- 
 ease is dependent on irritation in the bowels, or is sympathetic 
 of mischief occurring elsewhere, they exert no control over its 
 progress, and usually tend to aggravate it, if used before the 
 active symptoms have subsided ; whereas when the complaint 
 is of a purely neuralgic nature, and is unconnected with irrita- 
 tion in distant parts of the body, the continuous galvanic cur- 
 rent is often of essential service, and speedily mitigates the 
 patient's sufferings. In all cases, as soon as the sensibility of 
 the nerve has been subdued, and while the patient's limb is 
 weak and stiff from long-continued inactivity, electricity supplies 
 a stimulus, which assists materially in maintaining the nutrition 
 of the muscles, and restoring their healthy function. But if 
 employed before the pain has subsided, the interrupted current 
 very generally aggravates the patient's sufferings. 
 
 In like manner, cold has found eager partisans, who have 
 insiste<l on its value as an external application, especially in 
 the form of ice. I cannot, from experience, speak favorably 
 of its effects when so applied, inasmuch as it has failed in 
 almost every instance in which I have seen it tried ; but possi- 
 bly it may be useful in those cases which are aggravated by 
 warmth, and accompanied by a distressing sense of local 
 heat. 
 
 Some persons, however, protest against trusting in the 
 moderately benumbing effect of ice, and recommend the appli- 
 cation of a frigorific mixture to the part, capable of reducing 
 the temperature below zero of Fahrenheit's therm4)meter, and 
 producing complete anaesthesia. The proposer and chief advo-
 
 NEURALGIC RHEUMATISM. 407 
 
 cate of this plan of treatment is Dr. James Arnott, who has 
 published a series of eases successfully combated after this 
 method, at the Brighton Dispensary.* The frigorific mixture 
 employed is two parts of finely-pounded ice, and one part of 
 common salt, and this application usually produces complete 
 anaesthesia within five minutes. " If the mixture be properly 
 prepared," he says, "the moment it touches the part it be- 
 numbs it ; and the patient is hardly sensible of the application 
 until it begins to produce congelation. It is seldom spoken of 
 as a cold application ; it causes a slight smarting or tingling, 
 and is rather warm than cold." " After the application, when 
 the part first regains its sensibility, there is a similar sensation 
 of smarting, provided means be not adopted to prevent it." 
 But the mode of obviating this discomfort, " is to keep the heat 
 of the part for some time under its natural degree ; and the 
 application of a bladder containing cold water is the best mode 
 of effecting this."^ 
 
 In cases of sciatica, Dr. Arnott admits, congelation is not so 
 striking or so immediate in its effects as in lumbago, " which 
 usually yields to one application ;" but, he says, it is not the 
 less successful, though more than one application may be re- 
 quired. The mischievous reaction which is found to follow 
 the employment of ice as a benumbing agent, is not observed 
 after the use of the frigorific mixture of ice and salt, for "the 
 greater energy of this congelation at once subdues all opposi- 
 tion. It permanently depresses the vascular and nervous 
 energies, and at the same time probably modifies the local 
 actions," and, "although sensibility soon returns upon the 
 restoration of the natural temperature, it returns in its natural 
 or normal condition." 
 
 My own experience does not enable me to pronounce a posi- 
 tive opinion upon this plan of treatment, for I have witnessed 
 its effects in only three instances. In one case the frigorific 
 mixture was had recourse to during the acute or inflammatory 
 
 1 " On Neuralgic, Rheumatic, and other painful Affections," by James Ar- 
 nott, M.D. 
 ^ Loc. cit.
 
 408 SCIATICA, AND OTHER FORMS OF 
 
 Stage of the complaint, and the pain was lulled and the inflam- 
 matory action subdued. The patient, however, was taking 
 medicine internally at the same time, and it is difficult, there- 
 fore, to estimate precisely the influence exerted by the external 
 application. In the other two cases, which were instances of 
 chronic painful sciatica, with a sense of heavy weight and 
 numbness of the limb, following an acute inflammatory attack, 
 the mixture, though productive of momentary relief — the direct 
 result probably of anaesthesia — had no permanent effect on the 
 progress of the disease. Judging, therefore, from what I have 
 myself witnessed, as also from the known effects of benumbing 
 cold, I have come to the conclusion that, although this appli- 
 cation may possibly be useful in purely painful affections of 
 the nerve, in cases of congestion or commencing inflammation, 
 and in those cases again which, whatever their cause, are ag- 
 gravated by warmth and accompanied by a distressing sense of 
 local heat, it must necessarily fail in every instance in which 
 the pain arises from irritation in the alimentary canal or other 
 distant part, or in which inflammation has gone on to effusion 
 or to thickening of the sheath of the nerve ; for however much 
 cold may reduce inflammation and deaden pain arising from 
 local causes, it cannot get rid of the fluid poured out as the 
 product of inflammatory action, nor can it subdue pain attribu- 
 table to the persistent agency of distant causes. The instances, 
 however, cited by Dr. Arnott, seem to sIioav that the powerful 
 influence of this agent may be beneficially employed more 
 frequently than might, a priori, be expected. 
 
 Firm and continued pressure, as with a ligature or the 
 tourniquet, is another expedient which has been adopted for 
 the relief of the agonizing pain in certain formidable examples 
 of the disease. Applied for several successive hours, it is said 
 to have checked the violence of the paroxysm, and to have 
 prevented its occurrence in intermittent cases. But it utterly 
 failed in affording relief in the only instance in which I have 
 had recourse to its assistance, and I am unable, therefore, to do 
 more than record the fact that its virtues when thus employed 
 have been highly eulogized.
 
 NEURALGIC RHEUMATISM. 409 
 
 Terebinthinate and camphor liniments, and various stimulat- 
 ing oils, especially the oil of horse-chestnuts, have been lauded 
 as components of antisciatica embrocations, and, in some few 
 instances, have been productive of temporary relief, through 
 their agency as counter-irritants. In my hands, however, 
 anodyne applications have been much more uniformly success- 
 ful. A strip of flannel, soaked in a mixture containing equal 
 parts of laudanum, Hoffman's sether, and glycerin, to every 
 ounce of which twenty grains of the extract of belladonna have 
 been added, placed along the course of the nerve, and then 
 covered with oiled silk so as to prevent evaporation, has often 
 been the means of mitigating the severity of a paroxysm in a 
 marvelously short space of time, and, in some few instances, 
 has arrested the disease. Chloroform, employed in the same 
 manner, has also proved extremely serviceable. 
 
 Nothing, however, proves more generally efficacious than 
 sulphur applied externally. Whatever its mode of operation, 
 the fact remains that, employed in this manner, it often sub- 
 dues pain which has persisted in spite of all other remedies. In 
 many parts of England the sulphur ointment of the Pharmaco- 
 poeia is a favorite remedy among the poor for the cure of rheu- 
 matism, whether affecting the joints or other parts of the body, 
 and brief notices of its virtue when thus employed are to be 
 found sparsely scattered through our periodical literature. But 
 in no recognized treatise, with which I am acquainted, do I find 
 the slightest notice of the curative action of sulphur applied 
 externally ;^ and I am indebted to one of my hospital patients 
 for directing my attention to the subject. He was a man forty- 
 three years of age, who had been afflicted with sciatica in a 
 severe form above five months. He had undergone a long 
 course of medical treatment before he applied at the hospital, 
 
 1 Since the above was written, my attention has been directed by Dr. 
 Nicholson, ofRedditch, to a special treatise on Sulphur in the cure of rheuma- 
 tism, published by Mr. R W. Wallace, so long ago as 1820, in which he recom- 
 mends local sulphur fumigation, and the subsequent wrapping of the part in 
 flannel. Moreover, in the " Lancet" for March 7, 1835, vol. i, p. 810, there is 
 an interesting notice as to the curative effects of its external application, by 
 Mr. George Tucker. 
 27
 
 410 SCIATICA, AND OTHER FORMS OF 
 
 but without obtaining the least mitigation of suffering, and I 
 had already tried several remedies with little success, when a 
 friend induced him to put sulphur in his boots, and otherwise 
 apply the remedy externally. In four days he was much re- 
 lieved, and in less than a fortnight had recovered perfectly. 
 Since that time I have used it in seventeen chronic, non- 
 inflammatory cases ; and in six only did it fn\\ in giving relief. 
 In four cases the relief w^as complete and permanent, and 
 occurred within ten days after its application was commenced : 
 in three others considerable alleviation of pain w'as obtained, 
 but a complete cure was not effected, and in the remaining four 
 the relief was only partial and transient. Several of these 
 cases, however, occurred among my out-patients at St. George's 
 Hospital, and it is questionable whether the remedy was tried 
 fairly and perseveringly. 
 
 The mode in Avhich I usually employ it is to sprinkle thickly 
 with precipitated sulphur a piece of new flannel, in which the 
 whole of the affected limb is to be incased, from the foot up- 
 ward. This should be kept in its place by a bandage, and 
 when expense is not of importance, the whole limb so bandaged 
 should be covered with oiled silk or gutta-percha, which has the 
 effect not only of increasing the warmth, and confining the 
 vapor of the sulphur, but also of obviating the disagreeable 
 odor consequent on the application of the remedy. This band- 
 age should be kept applied day and night. Contrary to what 
 might be expected a priori, absorption of the sulphur takes 
 place rapidly, and the breath, the urine, the secretions from 
 the bowels, and the cutaneous exhalation unmistakably attest 
 its presence in the system. And this, probably, explains the 
 mystery of its action in mitigating or subduing the pain of 
 sciatica. For not only does the remedy find its way into the 
 circulation as readily, if not more so, than when administered 
 by the mouth, but it is applied to the affected part more directly, 
 more constantly, and in larger quantities than it can be under 
 any other mode of administration. The only exception to this 
 is wiien the skin is dry and inactive, in which case the sulphur 
 does not disappear, the excretions give no token of its absorp-
 
 NEURALGIC RHEUMATISM. 411 
 
 tion into the system, and the remofly fails in affording relief, 
 unless means are taken to stimulate cutaneous action. 
 
 Whatever the precise influence it exerts in sciatica, there 
 cannot be a doubt that its beneficial eflfects are most strikingly 
 displayed in chronic cases unattended by any symptoms of 
 inflammation — in cases in which the limb feels cold, and pain 
 is felt only on exertion. If any symptoms of inflammation are 
 present, and if the pain is excessive even when the limb is at 
 rest, then, according to my observation, sulphur is seldom of 
 any benefit, and in some instances may possibly aggravate the 
 pain. And if its action be to stimulate the capillary circula- 
 tion, as has been suggested by Sunderlin and others of the 
 German school, it is not difficult to conceive how its influence 
 may prove beneficial in certain instances, and no less prejudi- 
 cial in others. 
 
 I have hitherto made no mention of baths as curative agents 
 in this form of disease, nor is it necessary to do more than 
 briefly allude to them. When the cause of the disease has 
 passed away, and only pain remains, the effect of former mis- 
 chief, baths, if not wholly inoperative for good, are at all events 
 inadequate to eff*ect a cure. So, also, when the pain is attribu- 
 table to gastric or intestinal irritation, baths, if serviceable, 
 prove so by promoting free cutaneous action, and thus improv- 
 ing the general health, more than by any direct local influence 
 they exert. But when the origin of the mischief is rheumatic, 
 and the blood is charged with the morbific element, Avarm baths, 
 and vapor and hot-air baths, may be as useful as they are in 
 other forms of rheumatism. In some chronic cases, shower 
 baths prove excellent tonics, and go far toward eff"ecting the 
 eradication of the disorder; and cold bathing, more especially 
 in salt water, is an excellent adjuvant to medicine, in impart- 
 ing vigor to the system, and enabling it to throw off" the rem- 
 nants of the malady. In Russia the occasional use of a hot 
 bath or a vapor bath, immediately followed by a shower bath, 
 or an ordinary water bath, cold or tepid, according to circum- 
 stances, has a great repute as a powerful restorative of a healthy 
 cutaneous circulation, and this, together with certain other forms
 
 412 SCIATICA, AND OTHER FORMS OF 
 
 of rational hydropathy, in which strict attention to the daily 
 routine of life, rational habits, rational diet, rational exercise, 
 and rational repose, play an important part in the restoration 
 of health, will often enable us to effect a cure, even when our 
 best-directed efforts, when unassisted by these potent auxilia- 
 ries, have proved quite unavailing. 
 
 But if vapor and other artificial baths are sometimes of ser- 
 vice in this form of complaint, much more so are the natural 
 mineral waters. The springs of Bath, Harrogate, and Buxton 
 have long enjoyed a well merited reputation for the cure of 
 certain forms of this malady, and many of the Continental 
 spas are resorted to for the same purpose. The waters of Wood 
 Hall, in Lincolnshire, which contain iodine and bromine in large 
 quantities, are rising rapidly in estimation, and in more than 
 one instance I have known them afford relief which had proved 
 unattainable by other means. But before recommending a 
 patient to resort to any particular watering-place, it behooves 
 us to consider well the history of his case, the precise nature 
 of the symptoms, and his constitutional peculiarities, for the 
 various waters differ so greatly in their action, that if we tail 
 to select the spring adapted to his particular case, he will prob- 
 ably derive little benefit from their operation. 
 
 The preceding observations apply only to baths in which the 
 whole body is immersed, but it must not be forgotten that local 
 baths of various descriptions add greatly to the effect of other 
 treatment, particularly when the complaint is of rheumatic 
 origin. Even in the acute stage, warm fomentations, constantly 
 applied, afford much ease and comfort ; and their efficacy may 
 be increased by the addition of an alkaline and opiate solution, 
 as recommended in a previous chapter. When the disease has 
 assumed a chronic form, douches of hot, cold, or tepid water, 
 or douches of vapor, simple or medicated, repeatedly applied, 
 are often of the greatest service. They neither distress nor 
 exhaust the patient, but they stimulate and soothe the affected 
 parts, and assist in the re-establishment of their healthy func- 
 tions. Indeed, one of the most useful local applications is the 
 vapor douche applied to a part which has been smeared or
 
 NEURALGIC RHEUMATISM. 413 
 
 painted with some sedative extract or tincture mixed with gly- 
 cerin. It combines the influence of the sedative and the vapor 
 douche more eflfectually, I believe, than does the application of 
 medicated vapor. 
 
 On the same principle on which shower baths have been 
 found beneficial, various tonic medicines, such as quinia, iron, 
 zinc, and arsenic, have proved serviceable to patients of broken 
 health or weakly constitution. But they are not all equally 
 useful in every case. Quinia appears to be the most efficient rem- 
 edy, in proportion as the appetite has been bad, and the attacks 
 more or less distinctly intermittent, while iron proves most use- 
 ful in pallid or anaemic persons with a weak pulse and a feeble 
 circulation ; and zinc, when the patient is of an irritable con- 
 stitution, and the attacks are characterized by much spasmodic 
 action. Arsenic is most serviceable to those in whom the attacks 
 have been paroxysmal, and accompanied by symptoms of a ner- 
 vous character. Seldom, however, will either of these medicines 
 prove really efficient, unless preceded by the administration of 
 remedies directed against the state of system out of which the 
 primary mischief has arisen. If the attack is of rheumatic 
 origin, alkalies, colchicum, and anodynes are just as necessary 
 as in the more active forms of the disease, though, of course, 
 in doses proportionate to the severity of the symptoms ; and 
 so are vegetable bitters and alteratives, to restore a healthy 
 state of assimilation. Without the previous administration of 
 medicines such as these, to subdue present irritation, and pro- 
 vide against the further generation of the poison, quinia and 
 arsenic may be given in vain ; and, in like manner, anodynes 
 with colchicum, and other antirheumatic medicines, may be 
 ineffectual in affording permanent relief, unless followed by a 
 course of tonics. 
 
 There is one fact in regard to sciatica and other forms of 
 neuralgic rheumatism, which must not be allowed to pass with- 
 out notice, the more so as it has a direct practical bearing on 
 the treatment of many forms of this disease. I allude to the 
 presence of a large quantity of oxalate of lime in the urine. 
 Case after case has come under my notice, in which iodide of
 
 414 SCIATICA, AND OTHER FORMS OF 
 
 potassium, alkalies, colcliicum, guaiacum, warm baths, embro- 
 cations, and other expedients have been fruitlessly employed 
 before the patient came under my care, and in which micro- 
 scopical examination of the urine has revealed to me at once 
 the class of remedies necessary to relieve the patient's suffer- 
 ings. The cases in which oxaluria occurs are usually charac- 
 terized by nervous irritability and languor, rather than by fever 
 or arterial excitement, and the urine is often left unexamined 
 because it is clear, bright, and plentiful. Viewed, however, in 
 considerable quantity, it will usually present a peculiar green- 
 ish tint, and if it be allowed to remain for the space of two or 
 three hours, in a funnel-shaped glass, the deposit which occurs 
 will be found to contain the octohedral crystals of oxalate of 
 lime. In such cases the internal administration of nitromuriatic 
 acid in full doses,("ivi-x,) aided by an occasional brisk purgative, 
 the cold shower bath, or a cold douche down the spine, fol- 
 lowed by active manual friction, proves the most effectual, I 
 might almost say the only effectual, mode of getting rid of the 
 complaint. In no case of disease with which I am acquainted 
 does improvement follow more rapidly after the commencement 
 of treatment. But the effects of the treatment are most strik- 
 ing when it can be combined with change of air and scene. 
 For this is a form of complaint which usually occurs in persons 
 who lead a sedentary life and are closely engaged in study or 
 some other active mental exercise; and perfect relaxation of 
 mind is almost as useful in such cases as the most potent drugs 
 of our Pharmacopoeia. But as medicine, without due rest and 
 mental quietude, is of less avail than when assisted by such 
 auxiliaries, so change of scene and mental recreation rarely 
 prove effectual in removing the complaint without the aid of 
 proper remedies. Therefore, whenever a case occurs which 
 presents the conditions referred to, I make a point of recom- 
 mending change of air, as soon as I have satisfied myself that 
 the course of treatment pursued is proving beneficial to the pa- 
 tient. And when this plan is adopted, a few weeks' attention 
 to the general health, combined with judicious medical treat- 
 ment, usually succeeds in eradicating the disorder.
 
 NEURALGIC RHEUMATISM. 415 
 
 If it be asked how nitromuriatic acid operates in getting rid 
 of the oxalate of lime, and with it, as it does, of the nervous 
 pains, I answer, that we are just as ignorant of the matter as 
 on the first day when chemistry became a science. But to those 
 who show themselves unwilling to accept or act upon an ascer- 
 tained fact unless it can be supported by theory, I would reply 
 by suggesting, with Dr. Headland,^ that the action of nitro- 
 muriatic acid in checking the tendency to oxaluria may be by 
 serving as an oxidizing agent, and favoring the conversion of 
 oxalic acid into carbonic acid. Thus : 
 CA+0=2C02. 
 
 Be this as it may, the important practical fact remains, that 
 when sciatica is accompanied by the abnormal condition of the 
 urine before referred to, the remedies recommended have the 
 effect of removing that condition, and with it the wearing pain 
 down the sciatic nerve. 
 
 I have hitherto spoken only of affection of the great sciatic 
 nerve, because it affords some of the best examples of this par- 
 ticular form of rheuioatism. But not unfrequently the brachial 
 and the facial nerves are also implicated, and there are some 
 points relating to their affection which require a passing notice. 
 It must always be remembered that here, as in sciatica, the com 
 plaint may be rheumatic, or may be referable to other causes. 
 It may have arisen from long exposure to cold or draughts, or it 
 may be connected Avith agencies of a totally different nature. 
 The pain in the arm may be sympathetic of mischief in the 
 heart or in the brain ; and the pain in the face, of disease in the 
 antrum ; or in the teeth and their sockets, of disorder of the 
 stomach and intestinal canal, or of the irritation connected with 
 a gravid uterus. Many persons suffer invariably from face- 
 ache or toothache during pregnancy, as also when their stomach 
 or bowels are out of order. Therefore, when summoned to the 
 relief of a patient suffering from either of these forms of dis- 
 ease, the first point to be ascertained is that the disease is 
 really what it appears to be, a primary affection of the nerves 
 
 1 See Headland ■' On the Action of .Medicines." pp. 186-9.
 
 416 SCIATICA, AND OTHER FORMS OP 
 
 and tlieir fibrous sheaths, and not pain symptomatic of distant 
 local mischief. This being determined, the same general plan 
 of treatment should be pursued as has been already recom- 
 mended for the cure of sciatica. When the affection is purely 
 neuralgic, quinia in full doses ; the sulphate of zinc, pushed 
 until two scruples or a drachm are taken daily ; the sesqui- 
 carbonate of iron : or arsenic, each of which may be combined, 
 if necessary, with aconite, and aided in their action by a seda- 
 tive at night, and an occasional morning laxative, are usually 
 the most efficient internal remedies, and their salutary effects 
 may be greatly promoted by external anodyne applications. 
 Those already mentioned are often quite effectual for the relief 
 of the pain, but when they fail, chloroform or chloric ether, 
 applied in the palm of the hand to the seat of pain, sometimes 
 exerts a magically soothing influence, while at others the ex- 
 ternal application of hydrocyanic acid is attended with the hap- 
 piest results.' When the bra-chial nerve is the part at fault, 
 the various remedies which prove useful in sciatica may be tried 
 with a reasonable prospect of success, but, in this form of the 
 complaint, greater benefit is derived from a solution of aconi- 
 tine, or from the use of the aconitine or veratria ointment, than 
 from any other external application. 
 
 The following cases will serve to illustrate some of the points 
 already mentioned relative to treatment. 
 
 Case I. — On the 10th of January, 1853, I was asked to see 
 
 Colonel , aet. 57, who had been a martyr to sciatica in the 
 
 right leg nearly ten months. There was no gout in his family, 
 and he had never experienced an attack either of gout or rheu- 
 matism ; but some years ago, while in South America, he had 
 intermittent fever, followed by violent "tic" in the face. The 
 pain on the present occasion came on suddenly, soon after a 
 long fatiguing ride in a cold easterly wind. He was not aware 
 of having ricked or hurt himself, and could not account for the 
 invasion of the disease. Before he applied to me, he had taken 
 
 ' A lotion coniposecl of half an ounce of Pharmacopoeia acid, in combination 
 with two drachms of rose-water, and two drachms of glycerin, painted on the 
 seat of pain by means of a camel's-hair brush, is an application which I have 
 often found useful.
 
 NEURALGIC RHEUMATISM. 417 
 
 alkalies, colchicum, iodide of potassium, sulphur, guaiacum, 
 and various other internal remedies ; had applied blisters and 
 embrocations to the leg, and had been to Bath and Aix-la- 
 Chapclle without relief. 
 
 When I first saw him, he was thin and sallow, and was look- 
 ing much worn in consequence of long-continued want of rest. 
 He described the pain as being ordinarily of a dull, aching 
 character ; but it was aggravated in paroxysms, which gen- 
 erally occurred about twice a week, and often lasted several 
 hours, during which the whole limb quivered with pain. He 
 was easy while lying quiet, but the least attempt at motion 
 invariably induced acute pain in the hip, thigh, and leg. The 
 acts of coughing, sneezing, or laughing were also productive 
 of an attack. His tongue was clean and moist ; bowels usually 
 regular ; urine clear, but containing an unusual quantity of 
 oxalate of lime crystals ; pulse 84, soft. 
 
 As his history and present symptoms seemed to negative the 
 idea of his being truly rheumatic, and appeared to point to 
 neuralgia, connected probably with some obscure miasmatic 
 influence, as the cause of his suffering, I prescribed the follow- 
 ing remedies, viz. : 
 
 Tincturae Aconiti, T)\vj; 
 Quinae Disulphiitis, gr. iv ; 
 Acidi Sulphuric! Diluti, 5ss ; 
 Syrupi, 5iss ; 
 Decocti Uiuclionse, 5x. 
 M. ft. Haustus ter die sumendus. 
 
 Extracti Beliadonnfe, gr. j ; 
 Pil. Saponis Comp., gr. viij. 
 M. ft. Pilulse duaj omni nocte suiuendse. 
 
 Liquoris Opii Sedativi, 5vi ; 
 Extracti Belladonna^, 51 ; 
 Tincturae Aconiti, 3^ ; 
 Glj'cerini, ^'w. 
 
 M. ft. Lotio parti affectae more exposito applicanda. 
 
 A piece of lint wetted with the above lotion, and covered 
 
 with oiled silk, was applied along the course of the sciatic 
 
 nerve ; and the bowels were regulated by means of castor oil 
 
 and an occasional enema of warm water. As the digestive
 
 418 SCIATICA, AND OTHER FORMS OF 
 
 organs were not out of order, a generous diet was allowed. At 
 the expiration of three days the pain was much easier; he was 
 able to sleep several hours uninterruptedly during the night, 
 and could walk across the room by the aid of a stick, without 
 inducing any increase of suffering. On the 19th the pain had 
 so far subsided, that I deemed it expedient to omit the pill at 
 night, and to trust exclusively to the effect of the mixture and 
 the sedative lotion. The omission did not prevent his sleep- 
 ing ; on the contrary, he slept well, and felt more comfortable 
 next day. Indeed, his progress toward recovery was steady 
 and rapid. On the 25th the lotion was omitted, and the mix- 
 ture was ordered to be taken only twice a day. On the 30th a 
 simple quinine draught, with half a drachm of sulphate of mag- 
 nesia, was substituted for the bark and aconite ; and on the 
 8th of February, or within a month from the commencement 
 of treatment, he felt perfectly well, and all medicines were 
 omitted. 
 
 Case II. — Elizabeth Beasley, aet. 46, was admitted into the 
 Holland AVard of St. George's Hospital on the .1st of February, 
 1853, suffering from acute sciatica affecting both legs. The 
 attack, which came on suddenly a week before her admission 
 into the hospital, had been preceded for six days by wandering 
 pains in the limbs, without redness or swelling of the joints, 
 and had been accompanied from the first by cramps and start- 
 ings of the limbs. She had never before experienced an 
 attack. 
 
 On admission, the pain was of the most agonizing description. 
 Commencing in the lower part of the back, it shot through 
 both hips, and down the back of both legs as far as the ankles, 
 giving rise, at brief intervals, to violent cramp and starting of 
 the limb, with an aggravation of her previous suffering. The 
 act of coughing or sneezing, and the least attempt at motion in 
 bed, induced a paroxysm of this description ; and so also did 
 pressure, however slight, in the course of the nerve. She was 
 utterly unable to sleep ; her countenance was anxious, and por-
 
 NEURALGIC RHEUMATISM. 419 
 
 trayed the agony she was enduring ; the face was flushed ; her 
 skin was hot, and bathed in perspiration ; tongue exceedingly 
 furred ; bowels open ; urine scanty, high colored, and loaded 
 with lithates. Pulse 120. Catamenia regular. 
 
 As the history of the case afforded evidence of the existence 
 of rheumatism, it seemed probable that the extreme violence of 
 the pain might be attributable to rheumatic inflammation of 
 the sheath of the nerve ; and I was, therefore, induced not only 
 to administer alkalies and other antirheumatic medicines, but 
 to have recourse to calomel and opium. The following is the 
 form in which the remedies were prescribed : 
 
 Hydrargyri Chloridi, gr. iij ; 
 Opii, gr. i. 
 M. ft. Pilula ter die sumeada. 
 
 Haustus Senna; eras mane. 
 Potassii lodidi, gr. v; 
 Vini Colehici, Tt\xx ; 
 Potassae Bicarbonatis, 
 Potassae Acetatis, aa 3ij ; 
 Haustus Potassae Citratis, ^iss. 
 M. ft. Haustus Gta quaque hora sumendus. 
 Broth diet. 
 
 On the 5th, the urine had become clear, and had increased 
 in quantity, the violent cramps and startings of the limbs had 
 ceased, and the pain was easier. She complained, however, of 
 a sense of weight and numbness of the affected limb which she 
 had not before experienced. The remedies were continued as 
 before. On the 8th. there was still further improvement, and 
 the pill was ordered to be taken only twice a day. On the 
 10th, as the improvement continued, it was given only once 
 daily. On the 12th, there was no longer any numbness or 
 sense of increased weight in the limb, and therefore the pill 
 was discontinued. On the 18th, as little or no pain remained, 
 and she was somewhat weak, it was determined to omit the 
 draught, administer bark, combined, by way of precaution, 
 with liquor potassae and iodide of potassium. This she con- 
 tinued to take until March 2d, when, as there was no return of 
 pain, and she felt quite strong, she was permitted to return 
 home.
 
 420 SCIATICA, AND OTHER FORMS OF 
 
 Case III. — Thomas Lloyd, set. 29, was admitted into the 
 York Ward of St. George's Hospital on April 8th, 1857. A 
 clerk by occupation, he had not been exposed to any external 
 agencies likely to produce an attack of sciatica, but he had 
 been " out of sorts" for some months, and latterly had expe- 
 rienced wandering rheumatic pains. On the 28th of March, 
 he had been seized with shivering, followed by pain shooting 
 down the back of both thighs and legs as far as the ankles, and, 
 in spite of treatment, this had gradually increased up to the 
 date of his admission. 
 
 When I first saw him. he was suffering acutely from sciatica 
 in both legs, especially the right. The pain was excruciating, 
 even when he was at rest, and any attempt at motion gave rise 
 to involuntary starting of the limb, and occasionally to cramp 
 in the muscles of the calf. His skin Avns hot and perspiring; 
 tongue coated and white : saliva acid ; bowels reported regular ; 
 urine scanty, turbid, and acid. Pulse 96, small and irritable. 
 
 As the history of the case pointed clearly to true rheuma- 
 tism as the cause of the seizure, I determined to administer 
 alkaline remedies in the following manner, viz. : 
 
 PotassjE Acetatis, 
 Potasste Bicarboiiatis, aa 3ij ; 
 Misturas Guaiaci. ^iss. 
 M. ft. Haustus ter die sumendns. 
 
 At the same time, with the view of testing the efiicacy of 
 sulphur externally, I had it applied to the right leg only, in the 
 manner recommended at page 410 of this treatise. His diet 
 was restricted to beef tea. 
 
 By the 11th, the pain was easier in the left leg, and he had 
 lost all pain in the right leg, to which th? sulphur had been ap- 
 -plied. The tongue had become clean ; the bowels were acting 
 regularly ; and the urine was clear, but still acid. The medi- 
 cine was continued as before, but he was allowed fish for dinner. 
 
 On the 15th, he no longer complained of pain, and asked 
 leave to get up and dress. This was permitted, and he was 
 ordered "ordinary diet," and to take the medicine only twice 
 a day.
 
 NEURALGIC RHEUMATISM. 421 
 
 On the 19tli, slight rheumatic swelling- of the ankles took 
 place, but there was no recurrence of sciatica. The diet was 
 changed again to fish and beef tea, and the medicine was con- 
 tinued. 
 
 On the 23d, the swelling of the ankles had disappeared, and 
 it was judged safe to recur to ordinary diet. From this time 
 he gained strength daily : he had no recurrence of rheumatism 
 or sciatica, and was therefore permitted to leave the hospital 
 on the SOth. 
 
 Case IV. — John Collins, set.^S, was admitted into the 
 King's Ward of St. George's Hospital on December 16th, 
 1857, suffering from sciatica of the left side. The attack 
 commenced ten weeks previously, coincidently with pain and 
 swelling of the left foot and knee, and of both hands. The 
 swelling of the joints soon subsided under treatment, but the 
 sciatica had continued unabated. During the firf-t violence of 
 the attack, he had sweated profusely. 
 
 On admission, his complexion was pale and sallow ; the skin 
 cool ; tongue coated ; bowels very costive ; pulse 84, w'eak ; 
 urine clear, but acid. Appetite good. The pain down the 
 sciatic nerve was of a dull, wearing character, and did not 
 amount to acute suffering, except when he attempted to sit or 
 stand. His easy posture was lying on his back in bed, with 
 the knee slightly flexed. There was not any tenderness of the 
 nerve on pressure. 
 
 As the symptoms manifestly originated in true rheumatism, 
 and their persistence was probably connected wdth irritation of 
 the sacral plexus of nerves consequent on long-continued con- 
 stipation, the following medicines were prescribed, viz. : 
 
 Olei Tiglii, ir^i ; 
 
 Pilulae Colocynth. c. (Jalomelanae, gr. v. 
 M. ft. Pilula statim sumenda. 
 
 Pulveris Guaiaci, 
 Sulphuris Loti, 
 MagnesiiB Carbonatis, 
 Sodae Bicarbonatis, aa S^s. 
 M. ft. Pulvis tei- die suraendus.
 
 422 SCIATICA, AND OTHER FORMS OF 
 
 Tlie bezels acted freely during the ITtli and 18th, and on the 
 following day the pain down the sciatic nerve had ceased, and 
 his water was slightly alkaline. I therefore ordered the powder 
 to be repeated every morning only, and prescribed : 
 
 Haustus Cinchona^, ^iss ; ter die. 
 
 From this time he progressed favorably ; there was no re- 
 turn of pain ; and he left the hospital on the 25th. 
 
 Case V. — Georgiana King, get. 58, was admitted into the 
 Queen's Ward at St. George's Hospital on May 5th, 1858, 
 suiferino; from sciatica of the left side, of four months' duration. 
 The pain, which was severe, had not intermitted in the slightest 
 degree since the commencement of the attack ; it was aggra- 
 vated by motion, and w^as accompanied by occasional cramp and 
 starting of the leg. She had not experienced pain in other 
 parts of the body during present illness, neither had she been 
 previously subject to rheumatism, and she had never before 
 undergone an attack of sciatica. Blisters and liniments had 
 been applied externally, and various internal remedies had 
 been administered during the two months preceding her admis- 
 sion to St. George's Hospital, but nothing had afforded the 
 sliw-htest relief. 
 
 On admission, the aspect was healthy; the skin warm; 
 tongue clean and moist; bowels costive; urine clear and light 
 colored, and free from crystals of oxalate of lime. Pulse 108, 
 irrita))lc, and rather weak. The appetite was good. The 
 catamcnia had been absent since the age of thirty-four. The 
 p;iin extended from the left hip down to the ankle ; but no 
 specially tender spot could be discovered in the course of the 
 nerve. 
 
 As the bowels were confined, and as the condition of the 
 urine seemed to point to neuralgia rather than to true rheuma- 
 tism, as the cause of the pain, I ordered a large turpentine 
 enema to be administered at once, with the view of thoroughly
 
 NEURALGIC KHEUMATISM. 423 
 
 emptying the lower bowel ; and prescribed the following draught, 
 
 viz. : 
 
 Tincturje Aconiti, Ti|vj ; 
 H.iustus Cinchome, ^is3. 
 M. ft. Hanstus sextis horis sumendus. 
 
 At the same time, as her tongue was clean, and her digestive 
 organs appeared to be in good order, I gave her the ordinary 
 diet of the hospital. 
 
 On the 7th, as the bowels had not acted freely, it was 
 judged expedient to administer ten grains of colocynth and 
 calomel. 
 
 The pills were repeated on the Jrlth, and again on the 14th ; 
 but, with this exception, no alteration was made in the treat- 
 ment throughout the period of her residence in the hospital. From 
 the first, it was manifest that the medicine was exercising a 
 beneficial influence, for the severity of the pain subsided within 
 a few days. On the 18th all pain had ceased ; and on the 19th 
 she was permitted to leave the hospital. 
 
 Case VI. — Henry South, a laborer, set. 29, was admitted 
 into the King's Ward of St. George's Hospital, on the 29th of 
 September, 1858, suffering from sciatica of the left side. The 
 pain, which was of six months' duration, extended from the hip 
 down the thigh and leg. It was of a dull, wearing character, 
 but was much increased by motion, and by every act of strain- 
 ing, as in coughing, sneezing, and the like. For some length 
 of time he had not had a good night's rest; but his bowels were 
 regular, and the various bodily functions were regularly per- 
 formed. Warm baths, galvanism, and various internal remedies 
 were had recourse to, without relief ; and on the 30th of Octo- 
 ber, as no benefit had resulted, all medicines were omitted. 
 
 On the od of November, Mr. Charles Hunter, who was then 
 house surgeon, introduced a finely-perforated needle into the 
 cellular tissue at the lower border of the left buttock, and in- 
 jected three-quarters of a grain of the acetate of morphia.
 
 424 
 
 SCIATICA, NEURALGIA, ETC. 
 
 Within a few minutes the patient became drowsy ; and at the 
 expiration of three-quarters of an hour he fell asleep. The 
 next morning, his tongue was rather dry, and he vomited once; 
 but his pain was easier, and he said he had passed a quieter 
 night than he had done for some months. In the evening of 
 the 4th, the injection was repeated, the solution being intro- 
 duced into the cellular tissue of the right arm. He went to 
 sleep immediately the operation was concluded, and slept 
 soundly for five hours. When he awoke, he had less pain than 
 on the previous day. From this time his progress toward re- 
 covery was steady and rapid. Each "night the injection was 
 repeated, and day by day tBe pain decreased. In short, five 
 injections were found sufficient to subdue the pain ; and he left 
 the hospital on the 10th, free from uneasiness, and able to.walk 
 comfortably. No sickness or discomfort was produced, except 
 after the first injection.
 
 

 
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