Re-printed from Columbus Medical Journal, for July, 1883. 
A cute A rticular Rheumatism. 
BY E. O. BARDWELL. M.D., EMPORIUM, PA. 
Vice-President of the Elk County Medical Society, Member of the Medical Society of the 
State of Pennsylvania,of the National Association for the Protection of the Insane, etc. 
Acute Rheumatism is a pyretic movement, characterized by inflamma- 
tion of the fibrous surfaces of one or more joints as local phenomena. 
It is claimed by most writers that this abnormal condition is caused by 
an excess of acid in the blood, but when we recollect that an analysis of 
the blood does not indicate such an excess ; that the perspiration, although 
sour, is not notably acid, and that in all febrile movements we have an 
acid urinary secretion as a concomitant, it seems to me that some other 
reason must be looked for. The fact that an alkaline treatment was, and 
is, of much benefit, has seemed to confirm this view, but we now have an 
acid which is much more efficacious than any alkali in bringing the disease 
to a speedy and satisfactory termination. 
Some authors, notably Professor Austin Flint, deprecate the action of 
cold as an important feature in the etiology of this affection. In a brief 
history I shall show my data for believing cold to be a prime factor in 
many cases. 
I cannot think that nearly a century 'has carried us much in advance 
of the opinions of Cullen on this subject. He says, in "First lines of the 2 
Practice of Physic "The acute rheumatism generally arises from the 
application of cold to the body, when any way unusually warm, or when 
one part of the body is exposed to cold while the other parts are kept 
warm; or, lastly, when the application of cold is long continued, as it is 
when wet or moist clothes are applied to any part of the body." He also 
says :f "In the case of rheumatism, I suppose the most common remote 
cause of it, that is, cold applied, operates especially on the vessels of the 
joints, from their being less covered by a cellular texture than those of the 
intermediate parts of the limbs. I suppose further that the application of 
cold produces a constriction of the extreme vessels on the surface, and at the 
same time, an increase of tone of phlogistic diathesis in the course of them, 
from which arises an increased impetus of the blood, and at the same time, 
a resistance to the free passage of it, and consequently inflammation and 
pain. Further, I suppose that the resistance formed excites the vis medica- 
trix to a further increase of the impetus of the blood, and to support this a 
cold stage arises, a spasm is formed, and a pyrexia and phlogistic diathe- 
sis are produced in the whole system." 
When we add to these remarks of Cullen that the joints in a primary 
attack have usually been in a state of activity prior thereto, and the inter- 
nal vessels consequently turgescent, that hereditary predisposition appears 
to be a feature in some cases, and that in all cases a peculiar state of the 
economy predisposing, and rendering the patient liable to febrile move- 
ment from slight and at other times incompetent causes, is required, I have 
said as much of the causation of this disorder as my experience will war- 
rant, or, as in my opinion, the statements of other writers will authenticate. 
There can be no doubt but that the alkaline carbonates do abridge the 
disease and mitigate the symptoms, but it is an open question whether 
they do not merely act as depurants, and in this way hasten the elimina- 
tion of the morbific element. We certainly do observe during the exhibition 
of salicylic acid, a decided amelioration of all the symptotns, and in my 
hands a more speedy and satisfactory termination of the lesion. 
Morphia and some of the other preparations of opium, as analgesics, 
certainly should be dignified by some other cognomen than palliates in 
this affection ; under their use the sensory nerve fibres distributed to the 
painful joints are obtunded; they no longer convey impressions of pain 
to the central ganglia, and the remedy for the disease per se will certainly 
have a more rapid and lasting effect, either directly or indirectly, upon 
nervous centers which are not occupied in receiving sensory and transmit- 
ting motor impulses with little intermission to the diseased tissue. 
*Vol. II, page 10, Edinburgh 1791. page 23. 3 
To prevent the gastric disturbance and disagreeable nervous phenomena 
sometimes following the use of morphia, I have found one-grain doses of 
the following powder, administered co-incidently with the morphia, to be 
very efficacious: 
R.-Ipecacuanhae, 3 ij; 
Opii, 3 j; 
Camphorae, 3 iv; 
Sodii bicarb,, 3 ij.-M. 
This formula has been used for years by Eclectics, and is by them 
called Diaphoretic Powder. 
While I heartily deprecate the indiscriminate administration of opium in 
all cases where pain exists, I believe that in many cases its judicious em- 
ployment, by giving rest to a harassed, nervous system, and through it to 
the diseased part, forms the stepping-stone to recovery. When I speak of 
acid and digitalis in the following report of cases, I mean always the 
following formula : 
R.-Acidi salicylici, 
Sodii bicarb., aa. 3 iv; 
Tr. digitalis (fresh), 3 iv; 
Aquae, q.s. ad., 5 iij.-M. 
The soda is merely added for its action in rendering the acid soluble, 
and not in large enough amount to have any effect as an alkali. 
This county, "Cameron," is located in a western spur of the Allegheny 
Mountains, and the chief industry is lumbering; this necessitates the 
driving of logs out of the smaller streams to the local mills, or farther on 
into the river at Williamsport. Most of these streams are shallow, many 
of them but a few inches in depth, except during the floods which usually 
occur in April, caused by the melting snow and ice. These floods last 
but a few days, and the lumber has to be floated at that time. Log driv- 
ers get from four to five dollars per day and board during the drive, and 
men are always to be found at these prices. The logs pile up in the 
streams, and the men have to work hard with levers to loosen them, part 
of the time on the logs, and part of the time in ice cold water to their 
waists, and when the jam is broken, run briskly down the bank to a point 
where a log, or logs, have struck an obstruction and another jam is threat- 
ened. Plunged into icy water until thoroughly chilled, taking violent ex- 
ercise until well heated, and then jumping into water at 32°-these are 
the principal conditions under which acute rheumatism is evolved in this 
particular locality. I will mention a few cases : 
Case 1. W. M.; single, male, aged 22 years, had been driving logs 4 
three days when he was taken, April 29th, 1879, with a chill, and pains 
in his knees and ankles, which soon involved his wrists and elbows as 
well. I was called, and found his temperature 104°, pulse 84, joints 
somewhat swollen and very tender on pressure. He occupied the dorsal 
decubitus, and the slightest movement caused excruciating pain. His 
urine was scanty, and gave an acid reaction to litmus. He was bathed 
with a copious, sour smelling perspiration. 1 prescribed morphia sulph., 
in doses, to be repeated every three hours, or often enough to 
relieve the pain, and the acid mixture without digitalis, to be given every 
three hours. April 30; had rested fairly well, pulse 90, temperature 
103° ; complained of a dull pain in the cardiac region, but auscultation 
revealed nothing abnormal. Tr. digitalis was added to the prescription, 
and the treatment continued. May 1st; pulse 80, pain in the chest en- 
tirely gone, rested well the night before without morphia. No more mor- 
phia was given, but the other treatment was continued until May 4th, 
when defervescence was complete, pains entirely gone, and convalescence 
established. 
This young man had never been sick before; there was no history of 
rheumatism in his family, and the attack was directly traceable to exposure 
to cold and wet. He was advised to forego the pleasure of log-driving 
thereafter, and promised to do so. 
Case 2. F. D.; male, single, aged 24 years, working on drive; was 
taken April 30, 1879; primary attack, pulse 80, temperature 
typical case of acute rheumatism ; same treatment as case 1, with the ex- 
ception that digitalis was added from the first. Convalescent May 7th. 
Case 6. F. C.; male, married, aged 28 years; was called April 19, 
1880. Patient had been confined two days with slight fever, general pain 
and soreness; thought he had taken cold, and would recover without 
medical assistance. I found him groaning with pain, and unable to move 
without aid ; the knees, ankles and wrists'were involved; his pulse was 
95, temperature The same treatment was pursued as in case 2. 
Morphia was diminished the second day, and discontinued the third ; con- 
valescence was pronounced the ninth day. This case was primary, and 
presented no anterior history of rheumatism. He had been drawing bark, 
had become heated putting on the load, and had then ridden six miles in 
a rain storm unprotected; the next day, he was confined to the house. 
Case 8. W. M.; same as case 1. Called May 16, 1880; found my 
patient had forgotten his promise and disobeyed my instructions; the high 
wages had proved too great a temptation to him, and he had again been 5 
working on a drive. His temperature was 103°, not so high as before, 
nor were any of his symptoms so acute, but more persistent, convalescence 
npt being established until the twelfth day under the same treatment. No 
cardiac lesion was discovered, although he complained of considerable 
pain and uneasiness in that region. 
Gw 9. H. D.; male, single, aged 20 years, had been chopping until 
heated ; sat down in a cool, damp place, without a coat on, to eat his 
lunch; May 18, 1880, acute rheumatism was developed and I was« sent 
for ; pulse 90, temperature 104°. Morphia, acid and digitalis prescribed. 
Next day, temperature 103°, pam of course relieved. The third day, 
about the same in every way. Determined to try the alkaline treatment, 
and did so. Fourth day, pulse 100, temperature 104° ; fifth day, pulse 
90, temperature 104°, urine alkaline and other symptoms worse. I felt 
that 1 had no right to continue the treatment, although I would have 
liked to have tried a few days longer, but returned at once to the acid and 
digitalis. The next day, the sixth, temperature 102°, pulse 80, other 
symptoms, as pain and swelling of the joints, mitigated. Convalescence 
was pronounced the eleventh day, being retarded, I have no doubt, by 
the experiment. I have tried the same thing in two other cases, with es- 
sentially the same result. 
Case 20. W. M.; same as cases 1 and 8; taken April 16, 1882. Since 
his last attack in May, 1880, has enjoyed perfect health, and had appar- 
ently forgotten his former experience, and again gone on a drive. I told 
the messenger to get some one else, that my advice was fully as impor- 
tant as my medicine, if not more so, and that it was useless and highly 
unsatisfactory for me to attend him if he would not follow my instructions. 
The messenger was not prepared for such a reception, and returned six 
miles without seeing any other physician. The next day, April 17th, I 
was prevailed upon to go and see him. I found him suffering much from 
pain in the knees, ankles and chest, with slight, dry cough, pulse 100, tem- 
perature 103°. The old treatment was resumed The next day the pain 
in the joints was much better, but the cough and pain in the chest per- 
sisted. The heart was pulsating at the rate of 120 a minute, with slight 
irregularity. A physical examination revealed a pericardial friction mur 
mur, and also, at or near the apex, a soft, mitral systolic murmur. These 
signs, together with the irregular cardiac action, pain, and a sense of op- 
pression in the precordia, anxious expression and dyspnea, allowed me no 
room for doubt that endo-pericarditis existed. The treatment was con- 
tinued, with the addition of sinapisms to the precordia, and the adminis- 6 
tration of five-grain doses of carbonate of ammonia every two hours, in 
the hope that it would obviate liability to embolism. April 19 ; no change 
in condition apparent externally, except that pulse seemed softer; on 
auscultation, the friction murmur had disappeared, the mitral murmur was 
discernable but indistinct, percussion revealed a much enlarged area of 
cardiac dullness, which, together with the other signs, confirmed a diagno- 
sis of pericardial effusion, hydropericardium. The treatment from this 
time, on consisted principally, the joints being quiet, of digitalis and carbo- 
nate of ammonia, with topical applications of tr. iodine daily, which was 
continued for twelve days with very little amelioration of the symptoms. 
At the expiration of this time, however, the area of dullness began to 
diminish,and at the end of the fourth week from the inception of the disease, 
the patient was convalescent, with no other abnormality apparent on 
physical exploration, than a faint endo-cardial non-regurgitant murmur. 
The remainder of cases of which I have notes, were so like in their 
course and treatment to those outlined above that it will be unnecessary to 
do more than allude to them in the summary. 
The whole number of cases treated with the acid mixture and morphia, 
since March, 1879, 's 23- ®f this number three were females, aged, one 
20, one 35, and one 38 years; the remaining twenty were aged from 20 
to 30 years. Of the 23 cases, one male and two females had a family 
history of acute rheumatism, which may or may not have been a factor in 
the etiology; in the remaining twenty cases, the attack was directly trace- 
able to, and followed in a few hours, exposure to cold and wet, sixteen 
cases occurring among men engaged in log driving. 
The mean duration of the disease was 10 days ; the maximum 29 days, 
and the minimum 6 days. In four of the cases, three males and one 
female, the attack was not primary. In only one case were symptoms of 
cardiac lesion developed, either during the progress of the disease or sub- 
sequently, so far as known at the present time. The disease is supposed 
to terminate when there is total absence of pain, swelling and soreness, 
and complete defervescence, no relapse occurring. Of 13 cases reported 
by Prof. Austin Flint in the American Journal of the Medical Sciences, for 
July, 1863, treated with palliatives only, the mean duration of the disease 
was about 26 days. It should be borne in mind that opium was one of 
the palliatives employed, and the disease would no doubt have had a more 
protracted course without it. In.these 13 cases, an endo-cardial apex 
murmur occurred in three, and pericarditis in one. Of my 23 cases, only 
one suffered from either endo- or pericarditis, and this one was the only 7 
case in which digitalis was not administered from the commencement; 
hence, I infer that digitalis exhibited from the inception of the disease 
until its termination, possesses some power to prevent cardiac complica- 
tions. I have never seen any bad results whatever follow its use, and I 
may add that I have prescribed the fresh tincture in from io to 15 minim 
doses, ter in die, for two years in the same case, with practically no inter- 
missions, without observing anything like an accumulative action of the 
drug, and without any other than a beneficial effect. 
In deprecating the action of cold as a factor in the causation of acute 
rheumatism, it is begging the question to say that many people are exposed 
to cold without contracting the disease, and that a peculiar predisposition 
is essential to its development. This is the same with all diseases; under 
precisely the same conditions of environment, some are stricken with dis- 
ease and others left, rendering it obvious to a superficial observer that 
there are intrinsic processes operating beyond our ken, which render 
certain persons peculiarly susceptible to the inception of certain diseases 
at certain times. Of these processes, and the rationale of these idiosyn- 
cracies, we are, for the most part, profoundly ignorant, and it is perhaps 
as well to admit the fact as to write a chapter of explanation, which will 
be found, on analysis, to return by a circuitous route to the starting point.