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            ON



RHEUMATISM,
RHEUMATIC  GOUT,  AND  SCIATICA,
THEIR
PATHOLOGY,  SYMPTOMS,  AND  TREATMENT,
                    BY


   HENRY WILLIAM FULLER, M.D., Cantab.,
                   nt

FELLOW OF THE ROYAL COLLEGE OP PHYSICIANS, LONDON J ASSISTANT PHYSICIAN TO
             ST. GEORGE'S HOSPITAL, &C, &C.
SAMUEL S. & WILLIAM WOOD,

        261 PEAEL-STREET.
              1854. 

  " Rheumatismua si minus perite tractetur, non ad menses tantum, sed ad
annos etiam aliquot, immo per omnem adeo vitam,  miserum hand infre-
qnenter dlscruciat."
                                   Sydenhami  Opera, Cap. T, sect. vi. 
PREFACE.       JZt^K
   Above two thousand years ago, Hippocrates laid down the maxim,
 that  all theories  should be framed xara $votv OsupCuv.   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 consequences."1
   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 ref-
 erence to  the facts thus proved and established, to show  how conflict-
 ing opinions 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 expo-
 nents of the true nature of the disorder, and would have been enabled
 to estimate the force of any argument  opposed to his  preconceived
 opinions.   But so many obstacles presented themselves to  this arrange-
 ment, 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 scien-
 tific 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 trea-
 tise intended  to  be purely practical, their  insertion will, I  trust, be
 excused, on account of the information they afford 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
1 Whewell'a ' Inductive Sciences,' vol. i, p. 18. 
IV
PREFACE.
unnecessarily large.  But the importance 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 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 dan-
gerous consequences.   I have therefore  been unwilling to omit any-
thing which may lead to a just estimate  of their importance, to  a full
understanding of their physical signs and symptoms, and to  a due ap-
preciation of the various grounds  on which their treatment should be
based.
   I have availed myself of the labours of  my predecessors, wher-
ever  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
by 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 allowing  me to test the respective merits  of topical  applica-
 tions 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 most  acute
 and terrible form; I am also indebted to Dr. Blackall, Senior Phy-
 sician to the Dreadnought Hospital Ship; to Dr. Finoham, formerly
 Physician to the  Pimlico  Dispensary; and  to several other of my
 friends, for opportunities of treating the disease, or of witnessing the
 effect 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
knowledge on this important and fearful  disease.

    13, Manchester Square ;
        August, 1852. 
CONTENTS.
                            CHAPTER  I.

                        INTRODUCTION.


Rheumatism deserving of attentive study      ....      17
Commonly supposed to be attributable to cold.  Not so in reality    ;      18
General and local effects of cold,  as  ascertained  by observation and
    experiment   .      .      .       .       .      .      .      .   19, 20
Rheumatism sometimes ascribed to the combined influence of cold and
    moisture.  Objections to  this theory       ....  20—22
Probably due to the presence of a morbid matter in the blood.   Argu-
    ments in favor of this doctrine     .       .      .      t      .  22—27
Source of this morbid matter.  Facts in support of its being a  pro-
    duct of mal-assimilation, or vicious metamorphic action  .      .  27—30
Nature of the poison, probably lactic acid      .      .      .          30, 3l
Specific character of the poison ......  31—34
Predisposing and exciting  causes of rheumatism      .      .      .  31—36
Recapitulation and views of author as to the action of the rheumatic
    virus .........      37
                            CHAPTER  II.

ON THE RHEUMATIC  DIATHESIS, AND THE  CAUSES WHICH INFLUENCE IT3
                             DEVELOPMENT.

Circumstances which favor the development of rheumatism   .      .   38,39
The hereditary character of rheumatism.  Statistical observations on
    this subject   ........      40
Age at which the disease usually appears     ....      41
Form which it assumes at different ages .     .      .      .       .   41, 42
An acute attack does not strengthen the disposition to the disease    .      42
The class of persons and the sex most liable to its attacks    .       .      43
The effect of climate and season on its production     .       .       .44, 45
Statistical reports on these subjects     .....  46—48 
Vi
CONTENTS-.
CHAPTER lit
   ON  THE  SEAT OF RHEUMATISM, AND THE CLASSIFICATION OF
                        DIFFERENT VARIETIES.

                  i
Differences of opinion as to the seat of rheumatism    \      •      »
All parts of the body liable to suffer    .      .             •      '
The white fibrous tissue throughout  the body^especially liable to be
    attacked     .      .             .      •      •      *      '
Probable explanation of this fact                          »      *
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      %      .      i      »
Probable explanation of this circumstance                         »
The local symptoms assume a symmetrical arrangement      v      .
Classification of rheumatism           .      .
Chief characteristics Of its different varieties   .      .       i      .
ITS


  PAGfi
    49
49—51

    51
    52
    52
 62,53
    53
    5i
54—56
                          CHAPTER  IV.

            ON ACUTE  RHEUMATISM, OR  RHEUMATIC  FEVER:

Acute rheumatism, or rheumatic fever.  Its extreme danger  .      .      57
Age at which it occurs.   Its various modes of attack  .      .      .  58—59
Its symptoms general and local ......  59—61
The fever not commensurate with  the extent and  intensity of the arti-
    cular inflammation   .     .      .       .      .      .      .   62, 63
The perspiration often spoken of as " enfeebling and useless." Not so
    in reality     ....;.      k      i  63—65
Symptoms indicative of a subsidence of the disease          .      .      65
The stiffness which remains after the  subsidence  of the acute disease
    not to be mistaken for a chronic form of the disorder     .      .   65, 66
Ordinary duration of an'attack  Of acute rheumatism.  Opinions of
    different authors.  Results of author's observation       .      .   66,
Statistical report  on the duration of the disease      i      .      »
Can the paroxysm be arrested  or cut  short by treatment?   Grounds
    for author's opinion to the contrary, and explanation of the  cases
    which are often cited in proof of such an occurrence     .      .    67, 68
Various complications of the disease.  Their severity and importance      69
67
70
                           CHAPTER  V.

 ON THE TREATMENT  OF ACUTE  RHEUMATISM, OR RHEUMATIC  FEVER.
Various kinds of remedies have been employed.  Treatment  hitherto
    uncertain and contradictory.  Cause of this uncertainty   .      _  71,72 
CONTENTS.
vit
 Grounds on tohich the rational treatment of acute rheumatism should
     be based, and objects to be effected ...      .      .          72 73
 Means of fulfilling them               .       ,                       73* 74
 Value of different remedies    .....             74
   Bleeding.—When  and to what  extent  to  be employed.  Danger
               Which attends its injudicious use      ;      .      ,  74__7?
             Buffing and cupping of the blood not an indication for
               its repetition                               .          78 79
             Opinions of various physicians as to its efficacy, note  .   78, 79
 Purging.—When and to what extent advisable.   Cautions to be ob-
               served in its employment       ....  7"9__81
 Opium.—Ordinary mode of administration inefficient.  Dr. Corrigan's
               method  of  treatment by.  Result  of  author's expe-
               rience, with suggestions as to the value of the remedy
               in full and repeated doses       .      .      .      .   82 83
 Vapour and Hot air Baths.—Usually unnecessary in the acute stage
               of the disease.  Under  what circumstances to be em-
               ployed   •»...;;      85
 Mercury.—lf given so as to affect the mouth  almost always prejudi-
               cial.   When and how to be administered      .      .      86
 Tartar Emetic.—Laennec's opinion in regard to.  To be employed
               as an adjunct to other remedies .      .      »      .   86, 87
 Cinchona.—Dr. Haygarth's method  of administration.  Usually dan-
               gerous in the active stage of the disease.  When  and
               in what doses to be made use of.      .      .      .87, 88
 Colchicum.—Its curative power.  Its poisonous effects.   Class of cases
             ,  in which it isjmost strikingly beneficial.  Cautions to be
               observed in  its administration   .      .      .      .   89> 90
 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       .      .      .      .    90, 91
 Nitrate of Potash.—Report of  various physicians  as to the action of.
               Author's opinion as to its efficacy      .      .      .   91—-93
 Lemon Juice.—Effect attributed to it by Dr. Owen Rees.  Usually in-
               efficacious.  Average duration of  the disease  under
               this treatment   .      .       .      .       .      .    93,94
 Alkalies  and their Salts.—Their exceeding value  in acute rheuma-
               tism.   Inoperative in ordinary doses, and why.  Inad-
               equate to effect a speedy cure When unassisted by other
               remedies  .      .      .       .      .      .      .    94, 95
In the treatment of acute rheumatism each remedy or  class of reme-
    dies has been too exclusively relied upon   ....       95
Author's method of treatment.   Its rationale.   Success which has  at-
    tended it     .......      . 96—100
Value of topical applications as adjuncts to the general treatment    .      100
Experiments to prove the relative value of different topical applications      101 
Vill
CONTENTS.
Experiments tending to prove that  articular inflammation may be
    in some measure prevented by judicious fomentations  .
General rules for the diet during an acute attack
Cases in illustration of the treatment to be pursued  .
Remarks on the effect of the treatment in the above cases  .
Observations on the effect of the treatment in several other cases
 101, 102
     102
102—116
 116, 117
117—120
                          CHAPTER VI.

      ON THE CAUSES OF RHEUMATIC AFFECTION OF THE HEART.

Rheumatic affections of the heart long unknown and unsuspected  .        120
Now recognized as imparting to acute rheumatism its chief danger.   120, 121
Not generally due to metastasis      .....   121, 122
Information respecting the cause of their occurrence to be  gleaned
    from an inquiry into the causes which determine rheumatic ar-
    thritis      .......•  122—125
Treatment most effectual in preventing the access of cardiac inflam-
    mation    ........  125—127
Inflammation  not  the  only form of heart disease Which occurs in
    connection with rheumatism     .....        127
Grounds  of this opinion.—Evidence derived from the symptoms "|
                __.         during life
        "                    "      post-mortem examinations }  127—131
        "                    "      actual experiment
        "                    "      the condition of the blood
        "                    "      the difference in the frequen-
    cy of concurrent pulmonary inflammation in  different forms of
    rheumatic heart affection        .....  127—131
Objections to this opinion answered  .....  131—133
Practical hints to be derived from this view of the subject .      .        133
Summary of author's views respecting the occurrence of rheumatic
    inflammation of the heart ......    134,135
Summary of author's views respecting the occurrence of fibrinous
    deposition on the endocardium    .....        135
                         CHAPTER  VII.

   EHEUMATIC INFLAMMATION OF THE HEART.—ITS  PATHOLOGICAL
      EFFECTS.—ITS SYMPTOMS, PROGRESS, AND  TERMINATIONS.

Anatomical character of the pericardium : nature  of, and products
    resulting from, the inflammation to which it is subject. Influence
    which the mechanism of the pericardium exerts on the progress
    and termination of pericarditis   .....       136 
CONTENTS.
IX
Terminations of pericarditis.  Pathological effects observed when the
    disease terminates favorably, and also when unfavorably.  Con-
    dition of the parts varies greatly according to the period which
    has elapsed since the commencement of inflammation  .      .  136—138
Pericardium, when once inflamed, rarely restored to the condition of
    health     ........  138, 139
Pathological changes produced by endocarditis.   Where chiefly ob-
    served      ........  141, 142
The appearances presented by fibrinous vegetations vary in different
    cases, and at different stages of their existence  .       .       .  142, 143
Result of the microscopic examination of fibrinous vegetations      .       143
Consecutive changes which follow the deposition of fibrin on the valves 142—144
Comparative danger of pericarditis and endocarditis, and the conse-
    quences to which they give rise .                             144—146
Possibility of complete recoyery after an attack of endocarditis     .  146—149
Great improbability of complete recovery  when fibrinous deposits
    have taken  place on the valves, and why       .       .       .       148
Physical signs of pericarditis.
         Friction-sound.   Referable to the altered mechanism of the
           parts.  Its extreme value as a diagnostic sign.  Two dif-
           ferent causes of its cessation     ....  149—151
         Precordial dulness.  Not pathognomonic  of effusion,  but
           valuable as an accessory symptom of pericarditis, and as
           indicating the  increase  or decrease of effusion   .       .   151, 152
         Friction-thrill.   Its usual'position.  Under what circum-
           stances  present    ......       152
         Undulation.. Does not always exist, and why      .       .       153
 Practical inferences to he deduced from these signs, more  especially
     in reference to the nature of the prognosis     .      .       .       154
 Physical signs of endocarditis.
         Bellows-murmur.  Referable to the altered  mechanism of
                             the valves, and how  .      .       .  154, 155
              "             Mode  of distinguishing between disease
                              of the different valves     .       .  156—158
              "             Difficulties which occasionally present
                               themselves in forming a  diagnosis.
                               How to  be overcome       .       .  158—161
 General symptoms  of rheumatic carditis. Usually more marked in
     cases of pericarditis than in cases of endocarditis.  In some in-
     stances characteristic, in some altogether absent.  To  be valued
     accordingly      .      .      •      •      •      •       •  161—163
 Head symptoms, when occurring in the course of acute rheumatism,
     usually symptomatic  of cardiac inflammation   .       .       .  163—165
 Resume of  the principal facts relating to rheumatic inflammation of
     the heart, with hints  as to the  prognosis in different cases      .       166
 Abstract of 16 fatal cases of acute rheumatism, with a record of the
     appearances found on dissection  .....  166—178 
X
CONTENTS.
                          CHAPTER  VIII.
  ON THE TREATMENT  OF RHEUMATIC  INFLAMMATION OF THE HEART"*
 Chief points for consideration  in reference to rheumatic inflamma-
                                                                    PAGfl,
     tion of the heart  .......       179
 Calomel given so as to affect the system considered by some persons
     to be a safeguard for the heart.  Not so in reality      .      .       180
 Those_remedies only can assist in preserving the heart from mischief
     which have the power of warding off, or arresting, an attack of
     rheumatism       .      .      .      .      .       .      .       181
 Pathological conditions to be attended to in the treatment of rheum-
     atic cardiac inflammation .      .      .      .       .      .       182
 Venisection.  When and how far serviceable       <       .      .   182, 183
 Local bloodletting often useful.  Leeching, when  to be employed,
     and when cupping .......    184, 185
 Mercury.   Its action in rheumatic carditis.  How to be administer-
     ed.  Its effects sometimes difficult to obtain.  When most bene-
     ficial.  When prejudicial to the patient's safety .       .      .   185—189
 Opium.   Its  inestimable  value in  these cases.  Suggestion  as to
     whether it may not exercise some directly curative influence  .    189,190
Blisters.  Always useful.   When most efficient     .       .      .        191
Alkalies, colchicum, and diuretics, most important remedies      .        191
Rest and abstinence of the utmost consequence    .       .      .   191, 192
Symptoms which justify the commencement of active treatment   .   192—194
Caution to be observed in watching  for  any mischief about the
    heart, even during the patient's convalescence   .       .      .   194, 195
Treatment to be adopted, when much  irritability of the heart re-
    mains      .       .      ,
Cases illustrating the author's  plan  of treatment,  and showing the
    influence of remedies, and the share which each remedy takes in
    effecting a cure   .,.,.,,  195—206
195
                           CHAPTER IX.
     ON THE STATISTICS OF HEART  DISEASE IN  CONNECTION WITH
                             RHEUMATISM.
Statistical records of rheumatic heart affections most important    ,        207
Difficulties which present themselves in instituting a comparison be-
    tween the reports of various observers   .      .      .       ,207  208
Cases from which the author's inferences are drawn  .      .       .   209'210
Table exhibiting the proportion of cases  in which some form of^
                    heart affection occurred
                the proportion of cases in which recent heart af-
                    fection occurred
                the proportion of  cases in  which old-standing
                    heart disease existed   .
211 
CONTENTS.
XI
inferences as to the  proportion which  old-standing heart disease
    bears to acute and subacute rheumatism viewed conjointly, and
    to acute and sub-acute rheumatism taken separately    .      .       211
Proportion of cases of acute rheumatism in which some form of re-
    cent heart affection occurs, as shown by the experience of vari-
    ous observers      .......   211, 212
Facts tending to corroborate these results    ....       213
Observations in  reference to the frequency of pericarditis  in  acute
                                 rheumatism      .       *      .       213
        "      "       r<       frequency of  recent  endocardial
                                 affection in acute rheumatism  ,       214
0*bservatidns in reference to the relative frequency of recent exocar-
                                 dial and endocardial affection in
                                 acute rheumatism       .      .       215
Tables exhibiting the result of these observations   .       .      .       216.
Author's explanation of the  great excess in the frequency of endo-
     cardial affection  displayed in these tables       .       .      .       217
Influence of age in determining the access of cardiac affection    ,    217, 218
     "    of sex           "           "          "             .        219
Connection which exists between the form which the articular symp-
     toms assume and the liability to heart affection .       .      .    219, 220
 Period ofthe attack at which heart affection most commonly arises .    220, 221
 Heart affections observed less frequently in primary than  in  subse-
     quent attacks of acute rheumatism                         .   221, 222
 Pericarditis and true  inflammation of the  endocardium  more fre-
     quent  in primary  than in subsequent attacks of acute rheuma-
     tism                    .....              222
  Table i.—Exhibiting the  number of cases  of  acute and  sub-acute
             rheumatism, which  were complicated by disease of the
             heart;  the age and sex of the patients in whom it oc-
             curred  ; the form which it assumed; and the propor-
             tion in which each form occurred among the two sexes.   223, 224
 [ "'   n.—Exhibiting the same facts  in regard to  acute rheumatism,
             viewed separately      »».-..   224, 225
   "'  in.—Exhibiting the same facts in regard to sub-acute rheuma-
             tism, viewed separately ..                             225, 226
                           CHAPTER  X.

ON AFFECTIONS OP THE  BRAIN,  INFLAMMATION  OF  THE  LUNGS AND
   PLEURAE,  AND DISORGANIZANION  OF THE JOINTS, AS COMPLICATIONS
   AND CONSEQUENCES OF ACUTE RHEUMATISM.

Delirium occurring in the course of acute rheumatism, formerly re-
    ferred to inflammation of the brain :  sometimes, though rarely,
    referable to that cause    ......   227, 228 
XII
CONTENTS.
 More  generally connected with acute inflammation of some internal
     organ, and occurs sometimes without any  concurrent internal
     inflammation        .......      228
 True  interpretation  of the  head symptoms which  occur  in  acute
     rheumatism       .,.,...  228—233
 Convulsions and spasmodic actions  indicative of  spinal  irritation,
     are  due to precisely the same circumstances as the delirium and
     other symptoms referable to the brain      .... 233,  234
 Class of cases in which cerebro-spinal symptoms are most apt to  arise.
     Case in illustration   ......       234—239
 Cerebro-spinal symptoms always indicative of extreme danger, but not
     necessarily of a fatal issue  .      ,      .      .      .      .235
 Cases in illustration of the above-stated facts :—
     1st.  Cases in which there was  true inflammation of the brain   .     239
     2d.  Cases in which there was acute inflammation of some internal
             organ, but no inflammation of the brain  .      ..       240—242
     3d.  Cases in which there was neither inflammation of the brain,
            nor of any other internal organ   .      .       .       242—246
Cases illustrative of the severity whieh spinal symptoms may assume
    in connection with acute rheumatism      ....      245
Cases showing  that recovery may take place, even when the cerebro-
    spinal symptoms are most alarming       ....      246
Practical suggestions, as to the treatment of cases in which cerebro-
    spinal symptoms present themselves       .    v  .      ,      247__249
Inflammation of the lungs or pleurae, a most formidable complication
    of acute rheumatism ....... 249 250
Frequency of its occurrence     .....            250
Result  of Dr.  Latham's  experience.   Author's experience  at St.
    George's Hospital    ......            250'
Circumstances to be borne in mind, in the treatment of rheumatic in-
    flammation of the lungs     .....             251
Cases in illustration of the  severity of  the symptoms, and  of the
    treatment to be adopted     .....             952
Record of certain fatal cases, with the post-mortem appearances      253—255
Disorganization of the joints is another formidable complication of
    acute rheumatism    .                                        „_r  „_„
T . ,.,..   ...            '•••■•. 2o5, 256
Liability to its occurrence usually varies in  an inverse proportion to
    the  number of joints affected       .
Cases in illustration of the treatment to be adopted    .             " 25g  257
Record of post-mortem appearances in certain cases    .             "'as'^
Summary of treatment to be employed  .      .                    ' ~° ' 
CONTENTS.
XIII
    261
    261
    262
262, 263
    263

    263
    264
    264
                           CHAPTER XI.

                         ON RHEUMATIC GOUT.
                                                                    PAGE.
Rheumatic gout partakes in part of the nature of rheumatism, in part
    of that of gout      ....... 260, 261
In its acute form is liable to be mistaken for acute rheumatism
Closely connected with mal-assimilation
Age at whieh, and sex in whieh it most commonly occurs
Symptoms whieh mark its acute attack ....
Complications which attend it
Question, whether an attack which commences  as  acute rheumatism
    may not change its type, and terminate as rheumatic gout
Diagnosis of the disease in a chronic form
Distortions which it occasions   .       .      .
Nature of the changes induced in the joints   .      .       .       265—267
Mode of  determining the nature of the disease when deep-seated joints
     are affected  ........     268
Treatment of the acute form of the disease,  occurring in previously
     healthy persons.  Remedies which prove most useful     .       268—270
Means to be  employed when the  disease remains fixed in a particular
     point........      .271
Benefit to be derived from baths of various descriptions       .      . 271, 272
Treatment to be adopted when the patient is cachectic, and has under-
     gone repeated attacks of the disease       .      .       .       273—276
External applications which prove most beneficial under such, circum-
     stances.  The frequent necessity for their use.  To be varied ac-
     cording to the nature of the symptoms    .... 276, 277
General  rules in regard to diet, exercise, and clothing .       .      . 278, 279
Beneficial influence of change of scene and air, and curative effects of
     various thermal springs. Different baths useful in different cases  279—282
Cause of the extreme intractability of certain  cases   .       ,      . 282, 283
Necessity for caution in watching for the  supervention  of head-symp-
     toms, and for  taking active  and immediate  measures for their
     subjugation  ........     283
Pleurisy in connection  with rheumatic gout.  When most dangerous .     284
Inflammation of the eye.  Frequency of its occurrence. Part of the    ^!^
     eye  affected.  Treatment to be adopted    .      .       .       284—286
Table, exhibiting the temperature  and constituents of various thermal
     springs........286, 287
                          CHAPTER  XII.
                         CHRONIC RHEUMATISM.
Acute  and chronic  rheumatism identical in their source and nature.
    The acute may lapse into the chronic form, and the chronic may
    light up into an active state ......     288 
XIV
CONTENTS.
   PACK.
    288
    289
    292
289, 2<M)
290, 291

291, 292
Parts principally affected in chronic rheumatism
Muscular rheumatism, character of the pain    ....
Muscular rheumatism often leads to wasting of the limb
Lumbago.  Symptoms.  If neglected, apt to be very obstinate
Stiff or wry neck.  Character of the pain      ....
Intercostal  rheumatism.  Pain increased by inspiration.  How to be
    distinguished from pleurisy  ......
Symptoms  which characterise  affection  of the ligaments,  and the
    structures surrounding the joints  .....     292
Symptoms which accompany affection of the bursa; and synovial mem-
    brane .........292
Periosteal rheumatism.  Its symptoms  .....     292
Pain of  nodes  on  the  cranium liable *to be  mistaken for  ordinary
    headache    ........     293
Class of patients among whom periosteal rheumatism is most common     294
Pains of  chronic rheumatism most severe at night     .      .       .     294
  "        "        "      sometimes aggravated by heat   .       . 294, 295
Points to be remarked in the treatment of chronic rheumatism       . 295, 296
Valuable properties of the ammoniated Tincture of Guaiacum.  How
    to be used........296, 297
The Mistura Guaiaci and Powdered Guaiacum.  When serviceable   .     297
Terebinthinate medicines often beneficial       .... 297, 298
Colchicum. when useful  .......     298
Iodide of Potassium.  Most efficient in periosteal rheumatism .       .     298
Cod Liver Oil.  When, and how far beneficial  ....     298
Muriate of Ammonia of great value in muscular rheumatism .       . 298, 299
Mercury, when to be employed   ......     299
Value of opiates ........ 299, 300
Purgatives.  When most useful  ......     300
Local applications of great efficacy in lumbago and stiff neck .       .     301
Benefit to be derived from baths  ...... 301, 302
Blisters, when to be made use of .      .      .      .    «  .       .     302
Liniments and fomentations useful, not only in muscular rheumatism,
    but also when the joints are affected       .... 302, 303
Aconitine and Veratria Ointments.   Their singular  efficacy in  certain
    cases .........     303
An alcoholic solution of Aconitine to be employed, when the ointment
    is inapplicable       .......     304
Precautions to  be  taken  against cold, when the patient leaves the
    house  .........     304
Electricity and  acupuncturation.  Their respective merits  as curative
    agents......      .      .       . 304, 305
Good results occasionally accrue from a brief residence  in a warm
    climate      ........ 305, 306 
CONTENTS.
XV
                          CHAPTER XIII.

    ON SCIATICA, AND OTHER FORMS  OF NEURALGIC  RHEUMATISM.
                                                                   PAQB.
Rheumatism which attacks the nerves, easily distinguished  from other
    forms of rheumatism .......     307
Position and character of the pain in sciatica  .... 307, 308
Apt to prove intractable, and the reason why  ....     308
Points to be ascertained before deciding upon a plan of treatment    .     308
Diseases which have been mistaken for sciatica, and how they may be
    distinguished ........ 308, 309
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   .......       309—311
Diagnosis of effusion into the sheath of the nerve     .       .      . 312, 313
Remedies whieh prove most useful in checking effusion, and in pro-
    moting its absorption       ......     313
Acupuncturation, when and how far serviceable       .       .      .     314
Opium, belladonna, stramonium, hyoscyamus, and conium—their value
    as sedatives.  Their mode of action.  Points to be borne in mind
    before deciding on their administration   .      .       .       314—317
Efficacy of this class of remedies when applied externally     .      .     317
Other external applications have been made use of.  Which most ser-
    viceable      .      .      .      .     .      .      .      .     318
Influence of baths as curative agents   .....     318
Local baths of various descriptions of the greatest service    .      .     319
Quina, iron, arsenic, and other tonics: their  mode of action, and the
    circumstances under which they prove beneficial  .       .      . 319, 320
Points to be remembered in the diagnosis  of rheumatic affection of
    other nerves ........     320
In these instances, as in  the case of sciatica, a correct diagnosis ia
    essential to the adoption of efficient remedies     .       .      .     321
External applications which have been found serviceable      .      .     322 
 
RHEUMATISM,  RHEUMATIC  GOUT,

                   AND

          SCIATICA.
                     CHAPTER L

                  INTRODUCTION.

   Pew diseases are more deserving of attention than that
common,  painful, and obstinate  malady which has been
recognised under the title of Rheumatism.  Whether viewed
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 importance, however, in the estima-
tion of the physiologist is derived 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  unexplained, its treatment
unsatisfactory; and, by common consent, it is ascribed to ^
cause which affords not the slightest clue to its nature, nor
the least explanation of its varied phenomena.
  Many persons  consider exposure to cold sufficient to induce
an immediate attack, andjthough rheumatism not unfrequent-
ly occurs without the slightest exposure, though even when
exposure has 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 profes-
sion, 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.
                            2 
18
INTRODUCTION.
   Others have endeavoured 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 reten-
 tion of  effete matters in the blood, is  explanatory  of the
 varied phenomena of the disease.   But rheumatism may, and
 does sometimes 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 sus-
 pended 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 continu-
 ance.  Accordingly, of late years, a theory has been broached
 more consistent with the train of physical events, and rheu-
 matism has been  referred to the irritation of a morbid matter
 in the blood, which though possibly derived,  in  part, from
 stoppage of the perspiration, is to a far greater extent gene-
 rated in the system, as a product  of impaired or perverted
 assimilation—of vicious metamorphic action.
   This doctrine is as yet imperfectly understood, and even
 by its wannest advocates lias hardly been carried to its legit-
 imate conclusion.    It may  be well, therefore, to explain the
 grounds  on which its acceptance rests, to point out the  uni-
 versality of its application, and to show how  important is its
 practical  bearing.
   First,  however, it will be necessary to advert to the local
 and general effects of exposure to cold, as actually proved
 by experience.
   AVhen any part of the body is  subjected  to a low tempe-
 rature, or lo 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 moderate,  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
circulation in  the part is partially and sometimes almost
entirely  arrested, and when  warmth is  again applied, gan- 
INTRODUCTION.
19
grene 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 will probably be  frost-bitten and become
gangrenous  and  die.   In  every instance the local effects,
though  varying somewhat in different persons, are propor-
tioned, cateris paribus, to the intensity of the  cold and the
duration of the exposure, and are manifested only in the parts
exposed.
  The 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 contrac-
tion, and imparts  vigour to the system.  But intense  cold,
or  long-continued exposure  even to  a moderate  degree of
cold, has a  directly opposite effect.    It gives rise to  chilli-
ness, or  even shivering, with muscular and nervous  exhaus-
tion, a diminution in the force of the heart's action, and gen-
eral depression of all the natural functions.  This depressing
influence may proceed to such an extent as to  produce a
species of stupor, an almost irresistible desire to sleep, with
excessive feebleness of the heart's action, and death as its
natural result.
   It will be  observed, that  the phenomena produced  by
cold are totally unlike  the symptoms of rheumatism.  No
wandering pains; no redness or swelling of the joints ;  no
symptoms, 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
experience of travellers has proved beyond all question, that
in healthy persons, the most extreme  and rapid variations of
temperature are insufficient to excite the disease.1
  1 Captain Parry, in his account of ' A Voyage for the Discovery of a
\orth-\Ve.«,t  Pa^ge.' observes, (p.  134.) ''We were  constantly in the
habit for some months of undergoing a change of from 80° to 100°, and in
several instances of 120° of temperature, in less than a minute; and what
is most extraordinary, not a single inflammatory complaint, beyond a slight
cold, which was cured by common care in  a day or two, occurred during 
20
INTRODUCTION.
   Some  persons, however, maintain  that cold, though  of
itself inert, becomes a  powerful agent in the production of
rheumatism  when  acting in  conjunction with damp and
moisture.   Doubtless,  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 moisture, and that neverthe-
less, no instance  is on record in which  rheumatism  has  oc-
curred simultaneously in any large number of persons, is suf-
ficient 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 j1  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.2
   Indeed, it  needs little observation to prove, that 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

this particular period." Throughout the expedition, the occurrence of rheu-
matism, or  even indeed of rheumatic pains, was exceedingl}r  rare.
  Again, Colonel Sir J. Mitchell, in his 'Journal of an Expedition into the
Interior of Tropical Australia,' reports that '• they were almost daily subjected
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 oc-
curred among the troops stationed in different parts of the world, that out
of every 1000 patients admitted into the military hospitals, there are 57
cases of rheumatism at the Cape of Good Hope, the' land of heaths and ge-
raniums, and  30 only in the cold and variable climate of Nova  Scotia and
New  Brunswick.
  1 During the three or four  exceedingly cold days which immediately
preceded 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 greater
portion of the nights of the 5th, 6th, 7th, 8th, and 9th of February, '• the sol-
diers  had been  exposed  to the snow and frost," yet " no soldier presented
himself at  the  ambulance,*' 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 begun to suffer, not from rheumatism, but
from  " gangrene of the extremities, one of the common and true effects of
cold." (Baron Larrey's 'Memoires de Chirurgie Militaire,'  vol. iii.)
  * Pringle's ' Observations on Diseases of the Army.' 
INTRODUCTION.                    21
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°  Fahrenheit, 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
   But more than this: it frequently happens, that some ten
days after  the commencement of an attack, the  knee, or
some part which had previously escaped, becomes hot and
red, and swollen.  Whatever the cause  of the first articular
inflammation, the fresh  inflammation cannot  reasonably be
attributed to the effect 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 observation 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 sub-
sided,   the  symptoms recommence in  all their  severity
without fresh exposure,  and  without any obvious exciting
cause.   Even  had the  first attack arisen from cold, the
recurrence  of the disease, without fresh exposure, proves  it
totally independent of any such agency.
   The same fact is fully  and unequivocally attested  by the
  1 Numberless cases of this sort might be cited, but one which I take at
random from my note-book will suffice for an illustration  of the subject.
AVilliam Edmonds, aet. 34, who was admitted into St. George's Hospital on
the 30th of April, 1840, under the care of Mr. Keate. was confined to his bed
by severe ulceration  of his leg.  He was much out of health, but presented
no symptoms of rheumatism until the 25th of May, when, after lying in bed
for a period  of nearly four weeks, he was seized with wandering iheumatic
pains. These gradually increased in severity, and on the 1st of June, his right
hip became exquisitely painful, and both his hand and wrists red, swollen, and
inflamed. In  short, an attack of acute rheumatism commenced, and in spite of
treatment ran its usual course. Such instances have not escaped the noticeof
the observant Mons. Chomel; and accordingly, after quoting several in
point, he has expressed it as his opinion, (' Lecons de Clinique Medicale,' torn.
ii., p  153.) that '• the impression of cold is not a necessary precursor of acute
rheumatism." 
22
INTRODUCTION.
 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 ac-
 companied, by inflammation of the membranous envelopes of
 the heart.
   If they  were due to cold, 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 per-
 spiration by cold, they should certainly cease, or be in some
 measure relieved  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 refer-
 able to cold, the heart should surely escape unscathed, pro-
 tected as it is on all sides from the influence  of cold.  On
 this point experience  speaks decisivel}-,  and shows that for
 some time  the heart is not affected even under the influence
 of intense cold; and that when, after prolonged exposure, it
 is affected 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 symp-
toms 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 ma-
terial, 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 derange-
ment, but, if irritating in its nature, may give rise to local
inflammatory symptoms.   Assuming,  then, that an abnor-
mal condition'of the blood may account for the pain, inflam-
mation, and the curious train of symptoms which constitute
an attack  of acute  rheumatism, I shall endeavour 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 
INTRODUCTION.
23
quite characteristic of a disease dependent  on a  vitiated
condition 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 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
disease.  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 uncomforta-
ble ; his appetite has been capricious; he has had a sour or
bitter taste in his mouth, and  has experienced  dull, aching
pains in  his 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 mis-
chief.   The fever which accompanies local affections is
invariably  developed  after  the  commencement  of local
mischief, is commensurate with its intensity, and decreases
or increases in exact proportion  to the extent and intensity
of the local mischief; whereas in rheumatism, as in other
diseases  known to be dependent on a poisoned blood, it
generally precedes, for  a  considerable  time, the full develop-
ment of the local symptoms,  not  unfrequently decreases
directly local inflammation is set up,1  and is invariably aggra-
vated by its sudden or premature subsidence.
   So also  in  regard  to the  erratic  nature 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,
and  reappear  in some distant part  of the body.   On  the
"contrary, it is an admitted fact, that when any mischief is
really  local, the inflammation  is  also local and stationary.
On the other hand, whenever the blood is poisoned, as when
  1 "Febris autem sensim evanescit. manente dolore, quin et nonnunquam
inmanius satviente, materia scilicet febrili in artus translata."   (Syden-
hami Opera, sect, vi cap. v.) 
24
INTRODUCTION.
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  centres, may be
affected simultaneously or in succession, whilst the functions
of the skin, the liver, and the kidneys, may be also 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
condition of the circulating fluid.  For if the blood itself be
at fault,  it is but  consistent with reason to suppose that, per-
meating as it does every tissue of the body, it  should ulti-
mately give rise to similar changes in parts corresponding in
function and organisation, whereas, under any other suppo-
sition, the proneness of the disease to affect similar parts on
either side of the  body is utterly  inexplicable.   The peculi-
arity in question 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 presenting 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
formidable complications  of  rheumatism,  is  a fact  most
painfully verified by  experience, and it  is equally certain
that it  sometimes occurs prior  to  the setting-up  of any
articular  or other external symptoms of the disease.2  In
cases where it is preceded by pain, redness, and swelling  of
the joints, it has been ascribed to a transference of morbid
action consequent on the  subsidence  of articular inflamma-
tion.  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
1 'Medico-Chir. Trans.,' vol. x\v.
a See Cap. VI. of this Treatise. 
INTRODUCTION.
25
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 inflammatory action about
the heart is occasionally the earliest, and for some time the
only  local symptom  of rheumatism,  metastasis, however
vaguely  understood  and  applied,  must obviously  fail in
clearing  up  the  mystery.   Indeed the only explanation
appears to be that the heart is affected through the agency
of the blood, which from some cause has become unhealthy
and irritating in its character.1
   On the other hand, the symptoms usually observed when
metastasis does  in reality take  place,  when the  external
inflammation suddenly subsides, and cardiac  inflammation
simultaneously  or shortly  afterwards  commences,  afford
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 affected.  Rigors
almost invariably occur, followed by increase in the febrile
symptoms ; there is generally 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; hiccup  ensues, or vomiting, or
perhaps  diarrhoea supervenes, which, though usually  but
little under the control of medicine,  subsides together with
the other phenomena  on  the   re-establishment  of local
symptoms.2
  1 Mons. Chomel, among others, has recorded a series of most interesting
observations, which tend to show, that  the internal  inflammations in
rheumatism, like those of smallpox, typhus, scarlatina, &c, are referable to
an alteration of the animal fluids, more especially the blood.   (Lecons de
Clinique Medicate, 1834. pp. 529—539.)
  3 Dr. Holland remarks ('Medical Notes  and Reflections,'  cap. 'Metas-
tasis'),  '-The high state of fever, of notable disturbance of the heart, and
of other functional derangements which constantly occur during the trans-
lation 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, aet. 16,
under my own care at St. George's Hospital; another, that of a man in 
26                    INTRODUCTION.
   The fact is, the doctrine of a poisoned blood  in  rheuma-
tism, though seldom  fully recognised 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  acknowledged  and acted on  : the blood
itself being the source of irritation, the mere removal of one
of the local effects of that irritation would obviously be inef-
fectual  in eradicating the complaint; 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 analo-
gy between rheumatism  and gout.
   So curiously do these two disorders coincide, so impercep-
tible in certain  cases  is the transition from the one to the
other,  that there is no little difficulty in distinguishing be-
tween them.  In both an hereditary taint may frequently be
traced; in both, the fever is out of all proportion to the ex-
tent 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 its  attacks;  in  both, internal organs  are often impli-
cated, and in both, anomalous symptoms of a similar charac-
ter occur whenever metastasis  takes  place.   And  not only
so :—their affinity becomes  even more apparent when their
history is more  closely and  accurately examined.  For it is
then found that  whilst children of gouty parents are pecu-

King's Ward, under the care of my colleague, Dr. Wilson;  and the other
that of a lad admitted into Fuller's Ward, under the care of Dr. Seymour.
In all these cases there was extreme vascular excitement, with obsti-
nate vomiting, followed by diarrhoea.
  1 •' The heat,  redness, and swelling (of the joints) are no moiv the cause
of the consti'utional 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 general  in the system."  (Dr. Wilson on the True Character of
Acute Rheumatism, ' Lancet' for 1844, vol. ii, p. 192.) 
INTRODUCTION.
27
liarly subject to attacks of rheumatism,1 the offspring of a
rheumatic stock no  less frequently show  symptoms of that
hybrid disorder,  rheumatic  gout,  and in some  instances of
unequivocal  gout.    Such  a striking analogy between  the
symptoms of the two disorders is surely sufficient to warrant
our assuming a similarity of cause, and as in gout the exist-
ence of a materies morbi is admitted,2 our view is confirmed,
as to the existence of a poison in the blood in rheumatism.
   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 rheuma-
tism 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 most clearly denoting  functional de-
rangement.   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 sour3 disagreeable odour, whilst their urine, though usually
clear when passed, not  unfrequently deposits, on cooling, a
red brick-dust sediment, a sediment of the lithates and lac-
tates.  So constantly are these symptoms associated with a
tendency to  rheumatism, that they have been recognised as
indicative of  a " rheumatic diathesis," or, in other words, of
a state of constitution  peculiarly 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 the walls thickened in con-
sequence.   Moreover,  erratic pains 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.
  1 " Rheumatism is undoubtedly nearly allied to gout, and fits of it have
been more common in children born of gouty parents."  (Dr.  Heberden's
'Commentaries.'p.  399.)
  a'' In gout, there  is a materies morbi. which, whatever its  nature, is capa-
ble of accumulation in the system, of change of place within the body, and
of removal from it."  (Holland's'Medical Notes and Reflections,'  cap. on
' Gout.')
  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. 
28
INTRODUCTION.
    Again, it has been remarked, that whereas certain persons
  are subject  to  rheumatism, others under precisely the  same
  circumstances, 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, whilst
 others who had long labored under this  affliction, get  rid of
 their troublesome enemy in an equally remarkable and mys-
 terious 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 sys-
 tem, and is so generated as a result of some obscure consti-
 tutional peculiarity, some particular form of malassimilation.
   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 deranged.  It is so frequent an attendant on  disordered
 conditions of the uterine system, that its intimate connection
 with retained uterine secretions has  been suggested by Dr.
 Todd1 and other observers.   M. Chomel2 has been struck by
 the frequency of its occurrence after excessive lactation, after
 inordinate indulgence of the sexual desires, and durino- tedi-
 ous recoveries from fever ;3 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 con-
 stantly its attacks  have been preceded by functional deran°e-
 ment.                                                 °
  The important observation of Sir John Pringle,4 that rheu-
matism is more prevalent at the commencement of a cam-
  1 On ' Rheumatism.' p. 149.
  a'Lecons de Clinique Medicale,' torn, ii, p. 151.
  ' " Enfin on le voit souvent se manifester  pendant la faible*se qui occupe
toujours la convalescence."  (Op. cit, p. 407.)                     v
  * 'Observations on Diseases of the Army,' part i, cap. iii and iv; part ii,
cap  l; part m cap. m.                                  > r    > 
INTRODUCTION.
29
paign and shortly after return to garrison, than at any other
period of a soldier's career, comes in perfect confirmation of
these interesting 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 confinement 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 protected against  atmospheric vicissitudes,
and free from the many privations and the exposure insepar-
able 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.1  And if the general law of heredita-
ry affections, as  Dr. Holland asserts,2 be that  so ably devel-
oped 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 dur-
ing life, end with him, and have no  influence on  his proge-
ny,"  it follows  that  rheumatism, being  a 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
disorder.  For unless it be admitted that the materies morbi
may  be generated de nova in the system, the long continuance
and frequent recurrence of the articular symptoms are alto-
gether inexplicable.  If  the disease were dependent on a
poison introduced into the system from without, it should
manifest some of the peculiarities of disorders which acknow-
ledge such an origin; it should occur more or less periodical-
ly or  epidemically;  it should run a somewhat 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 varia-
ble and uncertain ;3  and so far from a well-developed attack
  1 See Cap. II, p. 32.
  a ' Medical Notes and Reflections,' cap. on " Hereditary Affections."
  8 In one case, it runs a short, acute, and regular course ; in another, the
patient experiences relapses, in each of which, the original symptoms not 
30
INTRODUCTION.
affording protection against its future invasion, it is general-
ly believed, that a person who has once been subjected to its
influence  is  peculiarly  liable  afterwards  to  its invasion.
And if, which is the only other supposition, the disease were
dependent on the irritation of a matter resulting from tem-
porary suspension of the skin's function, it should surely sub-
side on the re-establishment  of  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 pro-
duct of malassimilation, or faulty metamorphic action,  the
next points for consideration  are those which serve to indi-
cate its nature.
  A suggestion was thrown out  by Dr. Prout, and has been
adopted and enlarged upon by Dr. Todd in his Croonian Lec-
tures, 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 ac-
cumulates  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
consequence 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 dia-
thesis."
  Now, although the poison which gives rise to rheumatism
has not hitherto received actual demonstration, yet many
facts conduce 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 bv a draught
of cold air, and  subsides so soon  after reaction has taken
place, that we  are bound to admit its intimate connection
nnfrequently recur with all their former virulence ;  while, in a third case,
the disorder lingers on for months in a subacute form, aggravated by irre-
gularly periodical exacerbations. 
                        INTRODUCTION.                     31

with temporary suspension of cutaneous action.'  Moreover,
rheumatism is so common among persons suffering from renal
disease, and  other complaints accompanied by a harsh inac-
tive 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 their imperfect development, are
also 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
viewof getting rid  of some peccant matter, and the  secre-
tion is most profuse  at the very part where local inflamma-
tion is taking place.2  If the perspiration be checked, or take
place  irregularly or  imperfectly, the  disease is protracted,
and is rarely got rid of until  free cutaneous action has been
re-established.   It is probable, therefore, as the skin is  the
peculiar emunctory of lactic  acid,  that in  it we have discov-
ered  the actual materies morbi.3   Be this as it may, how-
ever, the ordinary symptoms  of the disease, no less than the
   1 This instructive fact may appear at first sight to countenance the hy-
 pothesis  of cold as the universal cause  of rheumatism.  But, in reality, it
 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 neces-
 sarily 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 notorious, 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 con-
 stantly generated de novo in the system, and its production being dependent
 on many contingent circumstances, its amount is indefinite, and the symp-
 toms therefore produced through its agency are  uncertain  and variable in
 their duration.
   2 I am not aware of having met with this remark in books ; and as the
 seat of inflammation is often the driest spot in the body, its accuracy may,
 perhaps, 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 excre-
 tion will there be found so abundant; whereas,  if no observation be made
 until progressive inflammation has greatly retarded the circulation, excre-
 tion from the part is almost necessarily arrested.
  3 Dr. C. J. B. AVilliams, among  others, expresses his belief in  the origin
of rheumatism from a poison, probably lactic acid, in the system.  (' Prin-
ciples of Medicine,' p. 116.) 
32
INTRODUCTION,
history of its  rarer modifications, are calculated to point  to
some excretion of the skin  as  the immediate cause of rheu-
matic inflammation.
  One other point, in connection with this  subject, is well
deserving 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 different poisons have  separate modes of action,
and produce each its own peculiar effect.1  What weight, for
instance, would be attached to the testimony of a man, who
stated that he had known the poison of glanders give rise to
hydrophobia, or that of measles to smallpox ?  Yet in what
disorder  are the general phenomena more striking, and the
local effects more singular 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.   But, in de-
fiance of those  very laws, the due appreciation of which
alone makes  any study  a  science, rheumatism  has been  re-
ferred 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 assimilation, to de-
fective or perverted uterine action, to the ill-performance  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
  1 " 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 of action, we can neither determine the seat and course of any given
disorder, nor judge  of the operation of remedies; whereas, if the definite
action of causes be allowed, we are 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.') 
INTRODUCTION.
33
the patient may at first sight have seemed to warrant.  Now
I will venture to assert, that although a dozen different pre-
disposing causes may tend to the production of the rheumatic
virus in the system, and a dozen different exciting causes may
each separately promote its action and give rise to the imme-
diate  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
in itself peculiar,—specific, as giving rise to a specific affec-
tion.
   Dr. Todd has suggested, that  disordered uterine secre-
tions may be  an occasional  cause of  rheumatism.  He con-
ceives,  " that the secretions of the uterus, if of an unhealthy
character, and not duly thrown off, may be absorbed into the
circulation and contaminate the blood, producing symptoms
of greater or less urgency, according  to the  nature and
quantity of the  morbid  secretion which  may have been ab-
sorbed."1
  1 ' On Rheumatism,' p. 149.  In support of his position, Dr. Todd cites
a case in which a state of protracted amenorrhcea, painful menstruation, and
disordered uterine  function, was entirely 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.  Whilst in the country she had exhibited well-
marked symptoms  of a rheumatic tendency, having suffered from wandering
rheumatic pains ; and when she came to London the rheumatic symptoms
increased, her health began to fail, and after a time the catamenia ceased.
In about six weeks after this she began to  suffer from severe uterine pains,
which continued for about five months, when an attaek 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 indi-
cations 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 disordered 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 rheumatic 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 rheumatic tendency, and that, when after reaching London,
her genera] health gave way, the functions  of the uterus became disturbed,
the monthly periods ceased, and the rheumatic virus, which is peculiarly
prone to affect any  part which is functionally deranged, attacked the womb,
and gave rise to the  uterine pain  and its attendant symptoms.  The pains
she suffered were truly rheumatic,  and were to be cured, as Dr. Locock has 
34
INTRODUCTION.
   Now, I am ready to admit,  that  nothing so  easily de-
ranges the whole female economy, produces more perverted
actions in the system, and- therefore tends more directly to
the generation 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 rheum-
atism, (and Dr. Todd himself has  adduced powerful argu-
ments 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 identical in nature with this said
product of malassimilation ; and to this, analogy would lead
us to demur.
   But although a specific poison, generated in the system as
the result  of  faulty metamorphic action,  is the  primary or
proximate  cause  of rheumatism, and constitutes the  actual
materies morbi, yet many agencies may conduce to the form-
ation of the poison and to its retention in the  system, and
many circumstances may render the body peculiarly suscepti-
ble of its influence.  These are the predisposing and exciting
causes of the disease.  Of all such causes, an inherited rheum-
atic  taint  is  unquestionably the  strongest.   It  exerts its
influence slowly, perhaps, but surely ;  and few who have suc-
ceeded to this unfortunate  inheritance, but at some period of
their life exhibit symptoms of that peculiar state  of system
which has been recognised under the title of the  " rheum-
atic  diathesis."   Thus  many  varieties   of functional dis-
turbance, many forms of hepatic and uterine derangement,
and those diseases of  the kidney connected with albuminous
urine,1 by impairing the general health, perverting the func-
tions of nutrition and secretion, and interfering, more or less,
with the skin's action, may become active agents in the pro-
duction of this predisposition.  Their morbid effects are not
confined to these particular organs—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
disturbance, and under certain  circumstances appears to in-
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 alt her previous suffering.
  1 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. 
INTRODUCTION.
35
duce a state of system favorable to the generation of rheum-
atic poison;  a state of system  arising,  be it  observed, not
as a direct and  immediate consequence  of suspended secre-
tion, but  as  a sequel of perverted function gradually taken
on by the system generally, in  consequence of imperfect  or
morbid local action.1
  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.   Excess-
ive venery and  long-continued  debauchery are in the  same
way frequently productive of  rheumatism, and so is im-
moderately protracted lactation. Many a woman  suffers, soon
after her confinement, if followed by great constitutional ex-
haustion, or as the reward  ©f her folly, in  inordinately pro-
tracting the period of suckling.   Chomel,  who observed the
frequency of the disease shortly after delivery, refers its ap-
pearance, under such circumstances, to  the sudden suppres-
sion of the lochial discharge.  Such an explanation, however,
does not hold good, for the lochia  can have no connection
with rheumatism, except as producing  functional derange-
ment, and so possibly tending  to favour 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  discharge had naturally and entirely
ceased; until, in fact, impaired nutrition had begun to follow
on the wear and  tear sustained by the constitution during
delivery,  or  during lactation carried beyond the patient's
strength.
  These,  then,  and many other instances  which might be
quoted, may fairly be included under the general expression,
that any thing which  disturbs  the general health and  gives
rise to a state of impaired assimilation, becomes, under cer-
tain  circumstances, a  predisposing  cause  of rheumatism.2

  1 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
contracting that disease, can predict with amazing accuracy the accession of
rheumatic inflammation of their joints, and not unfrequently of inflamma-
tion of the conjunctiva,  such as is apt to accompany rheumatism in un-
healthy or cachectic persons.
  2 I am glad to quote, in confirmation of my opinion, some admirable re-
marks 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 
36
INTRODUCTION.
 The only way, therefore, of preventing or counteracting it,
 is by noting the earliest symptoms of local disturbance, and
 taking active measures to prevent its continuance, by care-
 fully attending to the general health, and, lastly, as the skm
 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
 rheumatic poison is  present in the  system, any disturbing
 circumstance, even of temporary duration, such  as over fa-
 tigue, anxiety, grief, or anger,  by rendering the system more
 susceptible of its influence, may prove the accidental or ex-
 citing 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 more carefully its details  are examined, the more
 obvious does  it become that the disease does not result from
 the local agency of cold.1  But when after long-continued
 exposure, cold begins  to  exercise  a depressing influence on
 the system, it at once opens the door to  malassimilation, 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 depressing influence on the system, and
 thereby renders it more susceptible of the irritation  of the
poison, but by checking free cutaneous action it stops the
natural outlet of the morbific agent,  promotes its accumula-
tion in the system, and thereby tends directly to the develop-
 ment of the disease.
perhaps, of the fluids, as is more or less slowly induced, under the influence
of circumstances unfavorable to health, but often operating imperceptibly
and discovered only by very careful investigation ; I allude more particularly
to improprieties, not necessarily gross ones, in diet, clothing, or labour, 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.
Trans.,' vol. xxviii., pp. 462-3.)
  1 " 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 ' bv Dr J A
Wilson, ' Lancet,' 1844, p. 193.)                      '   J   '  '   ' 
INTRODUCTION.
37
   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 dis-
ease, is the presence of  a morbid matter in the blood, gene-
rated in the system as the product of a peculiar form of mal-
assimilation—of vicious metamorphic action. This poison it is
which excites the fever,1 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,
whilst if it exist in larger quantities, it rarely fails to cause
febrile  disturbance,  and to 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 one only out of several  internal inflammations  which  it
sets up coincidently with extensive articular mischief.  More-
over, 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 re-
peatedly without  exciting  inflammation  of the heart, so in
certain instances it may excite the peculiar train of symptoms
whereby rheumatic fever  is characterised, without producing,
from first to last, the slightest concurrent local inflammation,
whether of the joints or of the heart,  or any other  organ.2
  1  The fever in some instances may be aggravated by the local inflamma-
tions, but it is essentially independent of them, and is frequently well de-
veloped long before their commencement.
  2  I have met with several instances, in which  the development of rheu-
matic 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 whieh
no articular inflammation 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 lo rheumatic
fever, and who had previously suffered from attacks of fever with arthriti3
in the usual form ; and subsequently, on exposure to cold, were seized with
symptoms of pyrexia, which in intensity, duration, and every other particu-
lar,  were identical with these former fevers, save and except that, fiom be-
ginning to end, not a single joint was inflamed." 
CHAPTER  II.
   ON THE HEREDITARY 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 nu-
trition.   To determine the conditions which  favor the pro-
duction of such a state, to ascertain the laws which govern
its development, and to  discover, if possible,  some means of
checking or arresting its progress, is  a matter of some im-
portance ; and I will, therefore, endeavour to bring together
various circumstances 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 ad-
mirably adapted for  the full development of the disease ;
malassimilation is very likely to occur ; the skin performs its
function irregularly ; and the poison thus generated and  re-
tained 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 per-
fect  growth, for lack of sufficient nourishment.  The same
tendency to malassimilation may exist, but so much caution is
observed, and such immediate steps are taken  onthesb>htest 
        HEREDITARY DISPOSITION OF RHEUMATISM.     39

appearance of functional disturbance, to check or arrest the
progress of disease, that no root can be taken before that ele-
ment, which is essential to the growth of the seed, is  elim-
nated or got rid of from the system.  Thus, although a dispo-
sition 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 generally be warded off,
and the tendency to the disease, for a time at least, got rid
of.  There is, however, cause for serious apprehensions, when
rheumatic  symptoms have once  begun  to  manifest them-
selves, inasmuch as, however slight and trivial in their char-
acter, they are certain evidences of a constitutional change,
which may eventually terminate in a paroxysm of acute rheum-
atism ;  and the least want of caution, the least  exposure,
may induce an immediate and violent attack.
  The  hereditary disposition  of  rheumatism has been often
overlooked or disregarded.  Its existence, however, to a re-
markable 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 ad-
mitted into St. George's Hospital, I have traced it in nearly
29 per  cent. ;2 and M. Chomel distinctly  ascertained it in half
the cases admitted into the  Hotel  Dieu.3   Nor is this the
only evidence which can be offered in its favour.   M. Roche4
has expressed  his firm belief in its hereditary tendency; and
1 See Fir.-.t Medical Report of the Consumption Hospital.

            Cases of Acute Rheumatism, j  ^^hlf Pafent^   Per Cent.

 In St. Genrge's Hospital .   246           71          28.8
 Other Patients,  ....    37  ,  I       10          27.2
3 * L-cons de Clinique Me Jicale,' torn, ii, p. 120.
4 ' Dicti-mnnire de Medicine ct de Chirurjie pratiques.' 
40
INFLUENCE OF AGE IN MODIFYING
Dr. Macleod,1 and other physicians of eminence in this coun-
try, have  arrived at the same conclusion.  Moreover,  this
hereditary tendency exists  almost  invariably in  the cases
which are earliest and most  fully developed ;2 and we, there-
fore, cannot fail to join M. Chomel in exclaiming, that the
just and striking expression of Baillon3—" ut bonorum haere-
ditates, ita et morborum successiones ad posteros proveniunt"
—most fully applies to rheumatism.
   At what age, then, is this diathesis developed?  Or, to put
the question in a more practical form,—At what age  does
rheumatism 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 1-5, and compara-
tively few after the age of 50.
   It  must not be  supposed,  however, that rheumatism is
confined to the ages above 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 ad-
vanced life,  does, nevertheless,  invade our stiffening limbs
more commonly than some persons have been inclined to ad-
mit.4  The cause of the difference in the type of the  disorder
at different  ages, admits of  satisfactory  explanation.   As
rheumatism is due to the presence of a materies morbi, gene-
rated during the  destruction and reformation of the tissues,
processes which take place  with  unusual activity during
early life, and which take place more slowly as age advances,
it follows that malassimilation is more likely to be attended
with an abundant formation of the rheumatic poison, and
therefore, 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 a man's age advances,
and the system  becomes less able to bear  up against the
1* On Rheumatism,' p. 3.
2 See Table I. ai'p n ted to this Chapter.
3' Ballonu Consiiiorurn Medicinalium,' lib. iii.
4 See Tab. Ill, p. 47. 
THE FORM OF THE DISEASE.
41
wear and tear of severe illness, its  natural susceptibility to
acute disorders should be materially lessened.   It  thus  be-
comes comparatively insensible 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 in-
juries.  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.1
   A parity of reasoning, however, would lead us to antici-
pate a more constant tendency to the formation of the poison
in advanced years, and a more frequent occurrence of symp-
toms indicating  its  presence in the  system.   And such, is,
indeed, too frequently the case.   So common is malassimila-
tion 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 slighest 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 immediate vicinity.  Thus  months will sometimes pass
away, pointing with the heavy finger of suffering to the poi-
soned condition of the circulation.  In youth this is very seldom
the case.  The susceptibility of the system does not long re-
main unmoved:  either the  excretory organs are stimulated
to throw out the morbific matter, or if not, the constant pres-
ence of an irritant matter, which has accumulated sufficient-
ly 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 rheumatism.
   Sometimes, however, a person advanced in years does suf-
fer from acute rheumatism,  while, on the other hand, a per-
  1 The diminished suceptibility to initation exhibited by the system gene-
rally, is displayed most strikingly in the fibrous textures, the usual s^at of
rheumatic inflammation.  The great Bichat says, " Dans hs \ieil3ards, le
systeme fibreux devient de plus on plus dense et sene." 
42
RECURRENCE OF THE DISEASE.
son not yet passed his prime, is occasionally tormented with
the chronic form  of the disease.  And the phenomena ob-
served 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 consti-
tution,—one, therefore, whose system is still susceptible of
irritation,  and still prone to set up  acute inflammatory ac-
tion ; whilst, in the latter, the poison is either  generated in
small quantity, as  is evidenced by the slightness of the func-
tional disturbance, or the patient is  of a sluggish, inactive,
disposition,  and phlegmatic 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
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 con-
stitution is' blunted by age, yet that  the  variety in form
depends, not on any difference in the proximate cause of the
disease, not on any difference in the character of the materies
morbi, but on the quantity of the  poison present, on  the
nature of the constitution to be acted on by it,  and on the in-
fluence exerted by age  and  its accompanying changes in  the
system.  Such are  the agencies which modify the form which
the disease assumes, and the results of their operation will
be  seen by  an inspection  of Table  III, appended to this
Chapter.1
  It has been asserted, that the occurrence of an acute at-
tack of the  disease, tends  to strengthen the  disposition to
rheumatism.  But this is  certainly not the case.  A par-
oxysm is  evidently 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 inevi-
tably be a martyr  to rheumatism  for the remainder  of his
1 See page 47. 
      CLASS OF PERSONS AND THE SEX AFFECTED.      43

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 attended to.1
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 par-
oxysm be irregular and  ill-developed, rheumatic symptoms
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 a paroxysm of acute rheuma-
tism.  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
month previously, and ignorant of the real cause of the dis-
ease, is unwilling, even should his medical attendant recom-
mend 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 imme-
diately 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 rheum-
atism, call only for a passing remark, as a slight consider-
ation as to the cause of the disease will suffice to point out
its more  favorable victims.  Those persons are naturally the
chief sufferers who, through want and privations, irregularity
of life, and neglect  of their general health, are rendered most
liable to  that state  of malassimilation whereby the materies
  1 " Enfin quelques examples preuvent, que le Rheumatisme peut ne se
montrer qu'une fois dans tout le cour de la vie,"  (Chomel, op. cit., p. 124.) 
44         INFLUENCE OF CLIMATE AND SEASON.

morbi is produced;  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 influences 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 occur-
rence, rheumatism will be found more prevalent in the lower
than in the  upper ranks of society ;  and in its acute, no less
than in its chronic  forms, more frequent among  men than
among women.1
  Climate and season are generally supposed to have a pow-
erful influence over  the production of rheumatism.  Except,
however, as predisposing and  exciting causes, it has been
already shown that they can exercise no such power, and the
influence 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 emunc-
tory, 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 cutaneous action  is  comparatively sluggish.
For the same reason we should  expect it to prevail  chiefly
in cold, damp, and variable climates, for when moisture lends
its aid to cold in depressing the system generally, and thereby
favouring the  generation of the  poison, as  also in checking
                                                Males. Females.
  1 Out of 284 patients suffering from rheumatism admitted
   under my care, at St. George's Hospital, during the
   three years ending Juhy 31st, 1851, there were .    .   197   87
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    .     .    .606  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 2049, of winch     .    .  1410  639

                     Acute  Rheumatism.
Out of 289 cases of acute rheumatism admitted into St.
   George's Hospital during the four years ending De-
   cember 31st., 1848   .    .    .
Out of 136 cases of acute rheumatism recorded bj^ Dr.
   Latham ('Clinical Medicine,' p.  143.) ....
151  138

 75   61
Total number of cases 425, of which .    .     .   226   199 
           INFLUENCE OF CLIMATE AND SEASON.         45

perspiration, and thus preventing its escape from the system,
then we should consider all things favorable  for the  devel-
opment  of rheumatic symptoms.   Now facts are strictly in
keeping with these deductions.  It is not in the most inclem-
ent seasons nor  in  the coldest  climates that rheumatism is
most prevalent, but  at those  seasons  and in  those climates
remarkable for damp  and variable weather.1  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 Bruns-
wick as at the Cape of Good Hope, the  land of heaths and
geraniums.2   It further appears from  observations 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
towards the poles the symptoms of acute rheumatism are
almost unknown.3  In the one case the  skin's action is so
constant and profuse,  that the rheumatic poison, if gene-
rated,  is never allowed to accumulate in the system ; in the
other the mode of living being simple,  and the system at the
same time  vigorous, that form  of malassimilation whereby
the rheumatic poison is generated is little likely to occur, and
the essential, the  proximate cause of the disease being absent,
no rheumatism results from exposure to cold.
  1 See Table IV, appended to this Chapter.
  2 Out of 1000 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'
  3 Le Rheumatisme se presente rarement pres de l'equateur et des pdles
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.
462.) 
46
STATISTICAL REPORTS ON THE
                            Table I.

Table exhibiting the strong hereditary  tendency which exists amongst
  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 numbei of Cases.	Hereditary.	Not Hereditary.	Uncertain.	I have no Note on the subject.
Under 15 15 to 20 20—25 25—30 30—35 35—40 40—45 45—50 50-55 55—60	15 58 63 50 22 17 9 9 1 2	8 22 19 13 5 3 1	6 31 36 20 13 8 7 7 1 2	1 3 3 5 1 2	2 5 6 3 4 2 1
	246	71	137	15	23
  In all the four cases recorded  as  hereditary, in patients over the age of
35, the  disease had manifested itself  several times previously;  in  one,
indeed, no less than four  times, and two of tho?e who were between the
ages of 30 and 35 had experienced two previous attacks, and two others had
once before undergone a similar infliction.   But even taking the Table as it
stands, it exhibits the influence of an inherited predisposition in—
      1  out of everv 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 l'enfance  est ainsi  atteinte
contre la regie c'est presque toujours sous la triste influence de I'heredite."
                            Table II.

Table exhibiting the result of various Observations as to the Age at which
              Acute Rheumatism, most commonly occurs.

    Of 73 patients admitted into the  Hdpital dela Charite at Paris—
           2 were first attacked before the age of  .  ] 0
         35                  between the aires of 15 and 30
         22         «             ■<        ',      30  ,  45
           I         "             (:        (;      45  <•  60
           7         "        after the 60th year.
  t  „ •  mil  ,                             (Chomel, op. cit., p. 134.)
  In this Table however, M. Chomel  has included both gout and  rheuma-
tism, so that it shows too high an average in the later years. 
           OCCURRENCE OF ACUTE RHEUMATISM.           47

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.
                                  Macleod on 'Rheumatism,' p. 152.)
  Of 289  patients suffering  from  acute  rheumatism, 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,
however, does sometimes occur at a much earlier period of life.  I have had
under my  care, at the hospital, a child only 8 years old, suffering from dropsy
and diseased 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.   Dr.Ileberden 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 of acute rheumatism were admitted in chil-
dren of 3,  4, 5, 6, and 7 years of age, and upwards."
Table  III.
Table of 1014 Cases of Rheumatism and Rheumatic Gout, admitted into
  St. George's Hospital, during the  Four Years ending Dec. Zlst. 1848,
  showing the form of the disease, and the age and sex of the Patients.
Age.	Acute Rheumatism.	Subacute Rheumatism.	Chronic Rheu-matism.includ-lng Sciatica.	Rheumatic Gout.	Total.
5 to 10 10—15 15—20 20—25 25—30 30—35 35—40 40—45 45—50 50—55 55—60 60—65 65—70 70—75 75—80	Men. Women. 1 — 4 11 22 45 37 35 31 25 15 11 15 5 9 3 11 2 2 — 3 1 1 —	Men. Women. 2 — 4 3 17 10 26 10 23 12 13 9 10 4 3 4 5 1 2 — 2 —	Men. Women. 4 2 18 12 37 13 67 12 46 10 37 16 33 5 32 12 17 7 26 4 4 2 3 1 1 — 1 —	Men. Women. — 1 3 6 8 4 5 8 9 7 10 8 12 11 14 3 6 7 8 3 2 3 5 _	Men. Women. 3 — 12 17 60 73 108 62 126 57 83 37 72 33 57 23 62 18 27 14 39 8 7 5 8 1 1 — 1 —
	151 138	107 53	326 96	82 61	666 348
 
48
STATISTICAL  REPORTS.
                           Table  IV.

     Table  exhibiting the Influence of Season upon the 'production of
                           Rheumatism.

  Out of 284 Rheumatic patients, admitted as out-patients, under my care
at St. (ieorge's Hospital, during the three  years  ending  July 31st, 1851,
there occurred—
  In January, 26; in February, 25 ; in March, 23 ; in April, 27 = 101.
  -  May, 20; in June, 20;  in July, 24; in August 23  -   -   =93.
  ''  September, 29 ; in October, 20 ; in November. 21; in Dec-
      ember, 20   -    -    -    -    -     -    -    -    -  =  90.

  Out  of 1041 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—
January	Acute.	Subacute.	Chronic.	Rheum. Gout.	Total.
	27	13	44	14	98^1
February	27	12	23	10	97 UZ
March .	28	18	36	15	
April	23	15	27	11	76 J
May . .	30	14	40	16	100-j
June	21	10	34	21	86 1 9Qo 65 f "~b
July . .	14	10	27	14	
August, .	16	11	41	9	77 J
September .	22	16	45	15	98^1
October	27	11	Ol	5	j» 343
November .	28	19	29	10	
December .	26	11	39	3	79 J
	289	160	442	143	1014
 
CHAPTER  III.
             ON  THE  SEAT  OF RHEUMATISM,

  Much difference of opinion has  existed among physiol*
agists  as to the precise  localities or textures of the  body,
which become the seat of pain and inflammation in rheum-
atism.   Some  persons have  referred to the muscular  struc-
tures as the primary seat of the  disease, and have  main-
tained that other parts are attacked  in  consequence of their
proximity to those first affected.  Some have imagined the
tendons to be its primary seat, and  some  have confined its
action to the ligaments, whilst others taking a wider range
have given it a choice amongst all the fibrous textures of the
body.   Some, again, unwilling to recognise its constitutional
origin, and unable otherwise to  explain  the frequent shift-
ing  of its local  symptoms, have  suggested the aponeurotic
sheaths and the fasciae as its  seat, and supposing its effects to
spread  by continuity of surface, have thus  endeavored to
explain its attacks on various parts of the body.
  Now, looking at the difference in  these  theories, based as
they mostly are upon actual, though not  very extended, ob-
servation, it might fairly be  inferred that  no one texture is
exclusively the seat of irritation in rheumatism; and the his-
tory which has been given of the nature of the disease, borne
out  by many of its  most striking  phenomena, completely
establish  the correctness of this inference.   For if rheum-
atic 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 expos-
ed  to its influence, that all  must be more  or less liable to
suffer.  Such is the law  respecting the action of poisons in
general,1 and such, in fact, is found to be  the case in regard
  1 " It is seldom, that the action of poisons is limited to one membrane,
or organ, or system of organs, the greater number of these noxious agents
act on two or more organs, or system of organs."  (Dr. Williams ' On
Morbid Poisons,' vol. i, p. 4.) 
 50     OCCASIONAL COMPLICATIONS OF THE DISEASE.

 to the  rheumatic poison.  The  joints  and  the surrounding
 structures are the parts most commonly implicated; but not
 unfrequently the pericardium and endocardium, the investing
 and lining membranes of the heart, become the seat of rheum-
 atic inflammation, and  in some rare cases, the heart itself
 does  not escape entirely unscathed.1   The  uterus, the kid-
 neys,2  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.3   In some cases  active pleurisy supervenes, and
 more rarely inflammation of the sac of the peritoneum.4 The
 eyes occasionally suffer, as do also the  testes, and  the skin,5
 and  the periostium in various parts of the body.  Dr. Wat-
 son has reported rheumatism of the articulation of the jaw,
 Dr. Copland  and others of rheumatic  inflammation of the
membranes of the spinal cord, and instances of inflammatory
affection 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 eventually become involved in the mischief.  That such
   1 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 Pathological Society,' vol. ii.
   2 I have 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, however, is one which occurred in Iniversity College Hospital, under
the Care of Dr. A. T. Thompson, and which has been recorded by Dr. John
Taylor, (■ Med.-Chir. Trans.,' vol. xxviii.) '• The urine was not albuminous
on the patient's admission, but in a short time it became so highly charged
with this principle, as to assume  a solid form on being heated, and its
specific gravity at the same time amounted to 1050. After a few days more
no trace of albumen remained, and the urine had assumed its ordinary ap-
pearance and density."
   3 For cases  in point, see Chap. X,  of this  work.  Latham's 'Clinical
Medicine,' p. 101.   A  Paper by Dr. Wells, in the ' Transactions of a Soci-
ety,' &c, vol. iii, p. 406.  A Paper by Dr. John Taylor,' Med.-Chir. Trans.,'
vol. xxviii, pp. 511—13.
  * For cases in Illustration see Chap. VII. of this Treatise : as also' Andral's
Clinique,' p. 535, and 'Med.-Chir. Trans..' vol. xxviii,  p. 512.
  5 " 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 patchV (cutane-
ous) eruption was associated with the arthritic symptoms of ill-developed
rheumatic fever."   (Dr. Wilson on the true Character of  Acute Rheuma-
tism.  'Lancet,' 1844, vol. ii, p. 194.) 
         LIABILITY OF THE WHITE FIBROUS TISSUE.       51

complications would occasionally arise, might have been
expected, a priori, 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 particular 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 fibro-serous membranes in various parts of the body.
The parts, therefore, most commonly affected, are the joints
and their surrounding structures, the valvular apparatus of
the heart, and the fibro-serous covering  of  the heart,  the
strong white glistening sac of the pericardium.1
  The reason of this predilection of the rheumatic poison for
the fibrous and fibro-serous textures throughout the  body, is
not at first sight obvious, nor, indeed, after the most careful
consideration, can we assign to it other than a conjectural
cause.  But it is worthy of note, that  the textures most
commonly implicated in rheumatism, are all examples 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 consistent with  our knowledge respecting
the processes of nutrition and assimilation, to suppose that
  1  Dr. Law observes that the endocardium, more especially that part of
it which is usually the seat of rheumatic inflammation, has its correspond-
ing anatomical elements in the structure  of the joints;  the lining mem-
brane 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 peri-
cardium exhibits, in its compound constitution, its serous lamina corre-
sponding to the synovial membrane, 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 much more frequently the seat of rheumatic
inflammation than they are.  (See ' Dublin Med. Journal,' vol. xvi.) 
52
LIABILITY OF PARTICULAR JOINTS.
 each tissue selects from the blood, and appropriates to itself
 such matters as correspond with it in chemical constitution,
 we may readily conceive that some  peculiar attraction may
 be exerted by the fibrous and fibro-serous textures  for com-
 pounds, such  as  the  lithic  and lactic acids, to which they
 bear so strong an affinity.
  There are some curious facts in connection with this sub-
ject which  require particular  notice.  It has  long been
 observed, not only that the joints  and  their  surrounding
 structures are particularly liable to be affected by rheuma-
 tism, but that some joints are more prone than others to be
 attacked.  Those joints, for instance, which are most exposed,
 as the  knees, the feet  and  the ankles,  the wrists and the
 hands,  are the parts most  commonly implicated;  next in
 order, perhaps, follow 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
 mischief, are  more than ordinarily  apt  to  suffer.   Thus, a
 man falls down and sprains his ankle  or  his knee, and after
 a time,  with care and attention, he  entirely regains  the use
 of the  part,  and experiences  no inconvenience from his
 injury.  But if he is afterwards attacked by rheumatism, the
joint which had been formerly injured is almost certain to be
 affected, and will be so in every subsequent attack, and in
 all probability it  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.1  Blacksmiths, for instance, who
 wield a heavy hammer, very generally  suffer most in the
joints of the arm ; washerwomen in the  joints of the hands
 and fingers; gardeners,  and others accustomed to digging or
 stooping, are  exceedingly liable to  lumbago  and  sciatica;
 and postmen, 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
 matters as correspond with them in chemical  constitution
 is proportionably increased, and hence, the reason  of their
1 This fact, I believe, was first pointed out by Cruyeilhier. 
CLASSIFICATION OF RHEUMATISM.
63
being  affected prior and in preference to other parts  of the
body.1
   Another fact to which especial attention was first directed
by Dr. W. Budd  is, that, cateris paribus, corresponding parts
of the  body are similarly affected.   If one knee is  attacked,
it is probable, that  ere the close of the disease, more parti-
cularly if of long  duration, the other will become implicated
in the mischief; if one wrist suffers, the other will  eventual-
ly suffer also.   Nor is it strange if the local affection 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 suf-
fer 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 the blood.
   Whatever  the  part of the body attacked, the  aspect  of
rheumatism varies greatly in different cases.  Sometimes the
disease is acute ;  sometimes mild, both in its local and con-
stitutional 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 different varieties.  Strictly speaking,  any divi-
sion must necessarily be 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 there is nothing in  their pathology  to justify
such a separation.  But practically there is much advantage
in adopting some  artificial arrangement.  A well-marked dis-
tinction not unfrequently exists between the different varie-
ties : they appear to occur under different circumstances  of
age and constitution, and require treatment differing widely
in its character.   Hence it  becomes expedient to make such
practical distinctions as are calculated from their simplicity
  1  May not this be the true explanation of the fact, that the peii'-ardium
and endocardium suffer more frequently than do the fibro-serous 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 eve-
rything therefore is in a state to favour the irrhative action of the rheumatic
poison. 
 54      CHARACTERISTICS OF ACUTE RHEUMATISM.

 to  facilitate the description of the  various modifications of
 the disease, and those  which I propose  to  adopt  are, 1st,
 acute rheumatism, or rheumatic fever;1 2d, rheumatic gout;2
 3d,  chronic rheumatism; 4th, neuralgic rheumatism.
   Acute rheumatism,  as its name imports, is  characterised
 by 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 smell-
 ing  perspiration, 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, dis-
 playing in each great apparent intensity, yet rarely produc-
 ing  permanent  mischief, so that the joint which to-day seems
 to threaten  suppuration, may to-morrow evince  no mark of
 the  violent invasion it has undergone.   Sometimes the swell-
 ing  extends a considerable distance from the joint itself, and
 is evidently chiefly external to the articulation, for there is a
 puffiness about the parts  affected, and the hollows and de-
 pressions 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 effu-
 sion of fluid within the joint, for  the  distended capsule pro-
jects at  those parts where the surrounding tissues offer least
  1 Some persons cavil at the term, acute rheumatism, and urge the invari-
able adoption of the term rheumatic fever, as pointing to the constitutional
character of the disorder. But the fever which accompanies acute rheuma-
tism is one only out of many remarkable symptoms which characterise 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
disturbance 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 does 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.
  a By Dr. Macleod, these cases were classed with true rheumatism, under
the title of synovial rheumatism; but I believe they ho'd, as their phenome-
na would imply, a place intermediate between rheumatism and gout, and I
therefore propose to consider them  under the common and significant title of
Rheumatic Gout. 
DIFFERENT VARIETIES OF RHEUMATISM.        55
 resistance.  In most instances the two varieties of swelling
 are intimately blended, the diffuse fibrous symptoms predom-
 inating at one period of the disease, the synovial symptoms
 at another; but in proportion as the synovial symptoms be-
 come more prominent  and the diffuse fibrous symptoms less
 marked, so does the case  assume more and more the charac-
 ter 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
 lungs or pleurae.
   The  second variety presents characters of gout more or
 less blended with those of rheumatism.  It is frequently met
 with in persons who have  a taint of gout in their system, and
 seldom otherwise occurs in early life. It is not accompanied
 by the  profuse sweating of rheumatism, very seldom involves
 the heart or its membrane, but not unfrequently attacks the
 eye, the stomach, and the  lungs.  The articular inflammation
 is usually confined to one  or two joints, very generally affects
 the smaller joints, is  almost  wholly within  the  capsule, is
 much less migratory than in  true rheumatism, is marked by
 less  extended redness, and is accompanied  by less active
 symptoms of fever.  But  it is more  obstinate in its continu-
 ance, more apt, when in an acute  state, to induce disorgani-
 zation of the joints, more  prone, even in a less active form,
 to give  rise to permanent thickening and enlargement, and
 often to frightful and irremediable  distortion.
   In chronic rheumatism the pain is often  referred to the
 muscular structures, and is probably seated in the muscles
 themselves, their tendons  and fasciae; very little, if any, red-
 ness or  swelling is produced, but  the affected parts are stiff
 and painful, and  the pain  is aggravated by motion or pres-
 sure.   Sometimes, however, in cachectic states of the consti-
 tution, 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 sternum, the clavicle, and the cranium ; and if
 the seat of pain be carefully examined, there will be found a
 rough irregular swelling, arising from thickening of, and effu-
 sion  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, 
56        DIFFERENT VARIETIES OF RHEUMATISM.
but they are not red, and are seldom tender on pressure, as
are the inflamed joints during an acute attack.  The local
symptoms are migratory, though usually less  so than in the
acute form of the  disease;  there is seldom  much  sweating,
but little loading of the urine, and not much coating of the
tongue ; 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
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, inflammation
of which is  often  accompanied by effusion  and consequent
pressure on, and irritation of 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 fre-
quently gives rise.   For the  heart is  often damaged by the
violence of its attack, and becomes inapt for the purposes of
the circulation, and when this is the case, the mischief gra-
dually 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 artic-
ular rheumatism.
  Acute rheumatism is usually met with between the ages
of 15  and 50, few cases occuring 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.1  At whatever age it
makes its appearance it presents great  diversities in this mode
of attack.   It may commence without previous notable de-
rangement, either general or local: the patient may consider
himself 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, some-
times within a shorter period, is accompanied by redness and
swelling, and tenderness of the joints, as also by symptoms
of constitutional disturbance.
  In another case the attack  may  be ushered in by febrile
excitement,   marked  by  all  the characteristic features of
  1 For statistics and full particulars on these subjects, see Cap. II, of this
Treatise, pp. 44—48. 
58      ACUTE RHEUMATISM, OR RHEUMATIC FEVER.

rheumatic fever, yet unaccompanied by pain or the slightest
articular redness or swelling, and sometimes the disease may
even run its course unattended by pain  or local inflamma-
tion.  More commonly, however, after a certain period, pain
and inflammation make their appearance.  In most instances
the joints  and  the surrounding  structures  are  the parts
which first give evidence of irritation, but in some few cases
the heart or its membranes are affected for some time prior
to the setting up of articular mischief.1
  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 vicissitudes ; 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 well.
  His complexion is sallow and  unhealthy, his eyes are
dull,  and his conjunctivae yellowish.  The pulse,  perhaps,
is hardly above the natural standard, but his tongue is white
or coated, he has  a sour disagreeable taste in the mouth, the
urine is high coloured 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 attempt 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, when  a fit of shivering occurs,
unequivocal febrile symptoms declare themselves,  articular
inflammation commences, and he is obliged to take to his
bed.
  When once a paroxysm  is fully established the patient
presents a most pitiable spectacle of helpless suffering.  He
1 See Cap. VI, of this Treatise, Note. 
        GENERAL SYMPTOMS OF ACUTE  RHEUMATISM.     59

is exceedingly 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 aggra-
vate his already agonizing pain.  Even  the weight of the
bed-clothes is too much for him, and he generally asks to be
relieved from their pressure.  His expression  pourtrays the
suffering he  is enduring,  and  indicates,  at first  sight, the
severity of the disease.   Yet his aspect differs very remark-
ably from that of a person labouring 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 the skin.  Indeed the countenance 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  odour,  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  coloured and  offen-
sive.   The  urine is  scanty, dark  coloured,  and of  high
specific gravity, extremely acid, and loaded with the lithates,
which are deposited as  a copious, red,  brickdust sediment.1
The pulse is  accelerated, 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
  1 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 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
peculiar 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 aid of the microscope ; but usually, a 'few scales of epithelium,
together with an amorphous deposit of the 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. 
60       LOCAL SYMPTOMS OF ACUTE RHEUMATISM.

varies;  it is generally impaired, but occasionally  almost as
good as usual; and  thirst,  though  sometimes  excessive,
is  not  usually an urgent symptom.   From first  to last, if
the case be not  complicated by some  internal affection, the
head usually remains clear, the intellect  unobscured;  there
is no headache,  no delirium, neither is there subsultus tendi-
num, nor other  evidence  of the  disturbance of  the nervous
centres 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.   They at first  consist of little more than
pains wandering capriciously from  limb to limb, and  pro-
ducing  more or less temporary stiffness.    But when the
attack  is more fully established, the pains,  though shifting
from one spot to another, until  few parts of the body have
been left free from invasion, fix more particularly  upon the
larger joints.1   These rapidly pass into a state of inflamma-
tion, and become hot and 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; and the sur-
rounding  skin,  which had  been hitherto  moist  and  per-
spiring,  becomes thy,  tense,  and shining;  so much  so,
indeed, that experience alone  enables us  to predict  that
suppuration will not take place.
  Sometimes, however,  the parts present a somewhat dif-
ferent 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  fulness and distensionof the synovial mem-
brane, 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
   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 forms of the complaint; and I shall therefore defer entering  upon
their consideration until I speak of Chronic Rheumatism.        ° 
          PECULIARITIES OF ACUTE RHEUMATISM.        61

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  its character of true rheuma-
tism,  and  assume that  of the hybrid  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 very few hours, the enemy begins to  shift his
quarters, 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 evacua-
ting its first position and invading several joints successively,
inflammation not unfrequently recommences in its old quar-
ters, 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 through-
out the attack ; and it will be observed, that the obstinacy
and fixity  of the inflammation very  generally vary  in an
inverse proportion to the number of the joints  implicated.
   The subsidence of inflammatory action  at  one part, and
its  commencement  at  another  part  of the body, appear
sometimes  to be simultaneous actions, but  more commonly
the mutual dependence 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 inflam-
mation 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 inflammation  set up is obviously a
mere extension of the disease.
    Rheumatic  inflammation,  whatever its  character and ap-
parent intensity, very generally subsides without the  super-
 vention of the  ordinary ill effects of inflammatory action.1
 Sometimes, indeed,  as I shall presently point out, the joints
  11 here allude only to the articular inflammation, for when the heart, the
lungs, or the pleuras are attacked, the ordinary products of inflammatory
action are almost invariably produced. 
62
FREE PERSPIRATION BENEFICIAL
do go on to suppuration;  but more commonly the  redness
and  swelling disappear, the  skin  again  becomes  flaccid,
and  gradually 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 permanent ill
effects,  though varying greatly in  the rapidity of their oc-
currence,  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
towards evening, whilst, as morning advances, the unhappy
patient again experiences some remission  of his sufferings.
These curious alternations have been attributed by some to
mere variations in the external temperature ; and  the  oft
cited fact that the pains of rheumatism are sometimes aggra-
vated by heat, has been  confidently  appealed  to in support
of this  doctrine.1  But it matters not at what temperature
the air of the room  be kept, or whether the heat be  in-
creased 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 prevented ;  and the most ra-
tional 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 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 symp-
toms have been  established, as to cause  even cautious and
intelligent practitioners to mistake the nature of the impend-
ing attack.  Moreover, when febrile symptoms do thus pre-
cede the establishment of local inflammation, they  are not
only not increased by its occurrence,  but,  as was  remarked
by the sagacious and observant Sydenham,2 they are very gen-
  1 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 bv warmth, are loud-
est in the praises of the benefit accruing from profuse acid perspirations.
  3 Sydenham opera, sect, vi, cap. v. 
IN ACUTE RHEUMATISM.
63
erally 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 sub-
sides in some measure when these external  evidences  of in-
flammation present themselves.  Moreover,  it is usually less
severe when much effusion 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 colour.  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  liga-
ments and more deeply-seated  structures,  which  are  dense
and unyielding in their nature.   The former  cases are ac-
companied 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 migratory,  and shift
their  position more rapidly and more completely,  than  in
those last mentioned, in which,  for some days after all swell-
ing had subsided, there still  remains considerable  stiffness
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 rheuma-
tism, is commonly spoken of  as " wasting  and enfeebling,"
and is  said to distress and weaken the patient without alle-
viating  his  sufferings or  shortening  their duration.   This
opinion, however, is erroneous, and a mistake of some prac-
tical 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 escape be closed,  it will re-
quire 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 charac- 
64
SYMPTOMS INDICATIVE OF A
teristic sweats, and in these the pains  are always excessive,
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 ma-
teries morbi is in a 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 diarrhoea* diuresis, or extremely acid vomit-
ing, everything  which  tends to check them, tends also to
prevent the  elimination of the poison,  and so indefinitely 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 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 perspirations ; whilst 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 accumula-
tion 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 attempt at this system of
relief.  But I  would not be misunderstood  on this subject.
Though  the characteristic acid, sour smelling perspirations,
which occur in the natural course of the  disease, are unques-
tionably  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  constitu-
tion ; which occur after  the incautious use of the vapor bath,
or depletion carried to  an unwarrantable extent;  or which
again are sometimes witnessed towards the close of protract-
ed  cases.   Such  perspirations  are useless, wasting,  and
enfeebling:  though almost as profuse, they emit but little of
the characteristic odour ; 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 
               SUBSIDENCE OF THE DISEASE.            65

equally loaded state of urine, but, on the contrary, are accom-
panied by a soddened 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 lat-
ter are, in great meausure, the effect of  debility, are  enfee-
bling and pernicious in their continuance, and can and ought
to be arrested.  This distinction may easily be verified by
careful  observation,  and it is the more  important, because
any misunderstanding on the subject might lead to an erro-
neous system of treatment; to the forcible repression of per-
spiration, 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
swelling gradually  disappear, the  tongue becomes  less
coated, the evacuations  from the  bowels less fetid and less
dark coloured, the perspiration less profuse and less sour
smelling than before, and the urine more abundant and less
loaded with the 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 an-
ticipate 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, whilst the latter drops its sed-
iment, becomes more abundant, and contains a larger quan-
tity of salts, so that it retains its high  specific gravity, not-
withstanding 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, uncom-
plicated by an internal affection, recovery is usually complete,
and the patient  soon regains  his former vigour.  But in
cases in which the symptoms are ill-developed, or which oc-
cur 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 are  occasionally
attended by some amount of articular swelling.   In most
                           5 
66
OPINIONS RESPECTING THE
 instances  these pains gradually subside, and with them the
 tendency  to swelling of the joints; but in others they con-
 tinue for  several weeks, and do not  ultimately disappear
 until an acute paroxysm of the disease has been re-estab-
 lished, and the poison through  its  means  thoroughly elim-
 nated.
   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
 inflammation.  This must not be mistaken  for the subacute
 or chronic form of the disease just alluded to, as it is, doubt-
 less,  referable not to any persistent  cause  of irritation, but
 to the morbid condition in which the parts have been left.
 The  ligaments, tendons, fascia?, and aponeurotic sheaths,
 have  not recovered their normal  condition ; they are thick-
 ened  and less  elastic than they  ought to be, and the bursas
 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 disease which has sometimes been  called syno-
 vial rheumatism, but which I purpose describing  under the
 title of Rheumatic Gout.  When it does occur, it may be dis-
 tinguished from chronic rheumatism, by the dull aching na-
 ture 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 de-
 rangement.
   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 un-
toward, a period of two months scarcely serves to exhaust its
power of producing  even acute  symptoms."1  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 ;2 and
  1 On k Rheumatism,' p. 25.
  1 Le rheuraatisme articulaire -■ugu quelque soit la. medication employee ne
se termine jamais avant le vingtieme jour."  (La ' Lancette Fraucaise'  Au-
gust,  1834.)                                       *   ' 
            DURATION OF ACUTE RHEUMATISM.         67

Dr. Macleod imagined that, " with the common methods of
treatment, probably five or six weeks may be about its ave-
rage duration."1
  My own observation has led me to believe that even when
unattended by any internal affection, the  disease, under or-
dinary methods of treatment, endures from four to five weeks.
Of the 246 cases admitted into St. George's Hospital, during
the time I held the office of medical registrar, the great ma-
jority  were decidedly convalescent about the end of  the
fourth or the beginning of the fifth week from the commence-
ment of the attack, and were ready to  leave  the hospital
about the end of the sixth week.2  And of 23  other  cases,
part of which I noted at the Hotel Dieu at Paris, and part
at Addenbrooke's Hospital 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 shortening its duration ;  and to such
an  extent does this hold good, that, as I  hope to show, the
average duration of an uncomplicated attack may be reduced
by judicious treatment, from a month or five  weeks  to ten
days or a fortnight.
   Many circumstances,  however, must  obviously interfere
with this favorable issue.   An unhealthy cachectic state of
constitution,  an hereditary  predisposition, improper diet,
and injudicious  treatment, must  tend  materially to  impede
recovery, and so must an imperfect action of the skin, and
a sluggish and irregular action of the other excretory organs.
Under  such unfavorable conditions as these, it may be long
before  the system is freed from the poison, and the disease
may be indefinitely protracted.
   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, if treated vigor-
ously at first, it may be  at once cut  short.   My  evidence,
however, must be given in opposition to this pleasant theory.
Whilst 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 fever ;  I have watched with equal
1 On ' Rheumatism,' p. 25.
a See Table, appended to this Chapter. 
68        COMPLICATIONS OF ACUTE RHEUMATISM.
    care  all 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 value of different modes of treatment,  but it has
    never been my lot to  witness the results ascribed by different
    gentlemen, each to his own particular remedies.  Doubtless
    instances are occasionally met with in whieh the disease sub-
    sides  almost immediately under treatment, but such examples
    are rare, and in my observation have  occurred indifferently
    under all plans of treatment.   The  favorable result is ref-
    erable probably to some change induced in the functions of
    assimilation, by agencies altogether beyond  our ken, and it
    occurs so seldom that  it cannot be  fairly cited  as  indicating
   the possession of a power to arrest  or cut short 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
   commencement of the treatment, and not  from the actual
   beginning of the attack.  I have seen several patients recov-
   er  within four or five days after admission into the hospital,
   but in three cases only, under the  usual methods of treat-
   ment,  have the symptoms being thoroughly  subdued within
   fourteen days  from  the commencement of the attack.  In
   almost every instance of a supposed 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 marvellous rapidity with which
   the symptoms have subsided.
    I have hitherto  alluded solely to well-developed and un-
   complicated  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, how-
   ever, is often protracted, and rendered formidable by various
   complications.   One, which is observed chiefly  wdien catar-
l   rhal affections are prevalent,  is inflammation of the lungs or
I   their investing 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  conse-
   quence of the poison being determined to the lunjjs, 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 
          COMPLICATIONS OF ACUTE RHEUMATISM.       69

than 24 instances.  Moreover, in every instance in which the
case issued unfavorably, either pleurisy, pneumonia, or bron-
chitis, was present.1
  Another, and sometimes a serious  complication  of acute
rheumatism, though more usually of that form of the disease
termed rheumatic gout, is acute inflammation of the eye, gen-
erally of its sclerotic coat.  This seldom arises except where
there has been some cause of irritation to the visual organs,
and where, therefore, the poison of rheumatism has been spe-
cially determined to  the irritated part.   The proportion of
patients in whom it occurs is small; and in my experience,
it has almost invariably followed  exposure to draughts, or
other powerful  exciting  causes.  In no instance have the ar-
ticular symptoms appeared to  be relieved by its occurrence,
and I have, therefore, been led to regard it as a mere exten-
sion of the disease.
  Another and  most frightful complication of rheumatism is
inflammation of the brain, or its investing membranes ; an-
other is active maniacal delirium, sympathetic of inflammation
of the heart or lungs,  or of the vitiated condition of the cir-'
eulating fluid ;  and another is suppuration, or gradual disor-
ganization  of the  articular  structures.   These happily are
also rare occurrences.
  The most frequent, the most dangerous, and in its conse-
quences the most distressing complication of acute rheuma-
tism, is  inflammation of the heart and its membranous enve-
lopes.   This merits the most anxious  consideration of every
one interested 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.
1 Latham's ' Clinical Medicine,' pp. 164-5. 
70      STATISTICAL REPORT ON ACUTE RHEUMATISM.
TABLE
Exhibiting the Number of Cases of Acute Rheumatism, admitted into
  St.  Georges Hospital, in each month of the four years ending Decem-
  ber  2>lst, 1848. and marking the average length of time they remained
  in the  Hospital.   The great majority of these  Patients had been ill
 from fie to ten days prior to their admission into the Hospital.
				Number of Patients.	Average length of time in the Hospital.
January February March				27 27 28	Davo. 38 28 37
April May. June				23 30 21	32 28 431'
July August September October				14 16 22 27	37 54*' 31 32
November				28	33
December				26	283
Tota	1			280	Aver. 35
  1 The average of June is rendered unusually high by the occurrence of 1
case of 170, and of 1 of 144 days' duration.
  2 The average of August is abnormally raised bv 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 after the patients' admission and by the cure of 1 patieat
in 11 days.   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
 obstinacy 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  deliquium,
 have been recommended 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, whilst
 many have insisted, with equal warmth, upon the  benefit to
 be derived from the use of guaiacum and stimulant  diapho-
 retics.  Some have employed cinchona, some antimony ; some
 have recommended alkalies,  some acids; some have given
 nitre 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, wThen uncompli-
 cated by  cardiac affection, the disease usually terminates,
 sooner or later, in recovery,  and sometimes subsides, with
 marvellous rapidity, under every variety of remedy, it is
 obvious, that no sound inference can be drawn as to the suc-
 cess of any particular method  of  treatment, unless such
 treatment has been largely adopted, 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
treatment whieh 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 
 72         TREATMENT OF ACUTE RHEUMATISM.

 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, constitu-
 tion,  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, plethoric,  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 conse-
 quent attack of cardiac inflammation.   The opium, which in
 one person may prove of the greatest service in promoting
 free  perspiration, and in  allaying 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 secretions,  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 use-
 less or positively injurious at another ; and the conclusion is
 forced upon  us, that what is wanted, " is far less the dis-
 covery  of untried methods of  treating disease, than of dis-
criminative 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 years  our sur-
 mises respecting the origin  of rheumatism have been con-
 fessedly incorrect; our acquaintance with many of its com-
 monest and most important phenomena has been imperfect.
 Hence it has been difficult to make choice of proper reme-
 dies, and to apportion them rightly to the relief of the disease.
 Of late, however, rapid progress has been made towards a
 full understanding  of the nature of the malady.   Constant
 and  diligent pathological  research, by collecting  many in-
 ternal lesions with 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 evi-
 dence of its ravages obtained after  death, has  served to fill
 up and illustrate the few uncertain pages of its history.   So
 that,  from the knowledge we  have  now  acquired, we are 
           TREATMENT OF ACUTE RHEUMATISM.          73

justified in concluding, that its symptoms are  dependent on
the presence, in the system, of a materies 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 irritation.   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 induce dis-
organization of the joints ;  although the disease be accom-
panied 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 recognise 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 pro-
moting the elimination of the  morbific element, 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 materies 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 neutraliza-
tion be effected, its irritative property probably diminished,
and its elimination promoted by a free exhibition  of alkalies
and neutral salts ; and these objects may be further advanced
by the administration of purgatives, sudorifics, and diuretics,
to act upon the various  excretions.  With the  view of check-
ing the further formation of the poison, and of restoring that
healthy state of assimilation, which,  at the outset of the dis-
ease,  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
quina, 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 
74
TREATMENT OF ACUTE RHEUMATISM
system, and more particularly the irritability of the heart,
opium, conium, and nitre, together with the cautious admin-
istration of antimony, are remedies  of the greatest value;
and, if vascular action be excessive, and secretion sluggish,
bloodletting may be sometimes beneficially employed.
   Such is the rationale of the treatment to be adopted.
Where 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 venassection.  In no disease is the febrile heat greater, the
pulse fuller or  more bounding, the local inflammation appa-
rently 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  depletion promise greater
success.   Accordingly, from  the  time  of Sydenham, free
bloodletting 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.   Amongst the most recent
and  strenuous advocates of  large and  repeated bleedings,
have been Mons. Bouillaud in France, and Dr. Macleod in
England.   These gentlemen  recommended the abstraction
of three  or four pints of blood in the course of the first few
days of the attack.1   They endeavour 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 bloodletting  does certainly  appear to mitigate, for

  1 From three to six  pints of blood were usually abstracted by M. Bouillaud,
on the first three or lour days of the attack ;  and Dr. Maeleod 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 ' Rheumatism,' p. 32.) 
OR RHEUMATIC FEVER.
75
a time, the  severity of the symptoms, and to render  them
more amenable  to  other treatment.  But if some cases re-
cover marvellously under its influence, so do they under the
use of milder remedies : if in some instances patients go on
to recovery without the occurrence of any untoward symptom,
a far greater number experience relapses in which the dis-
ease 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 suffering.  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 venisection for their  relief, still, as
these symptoms, if left to themselves,  almost invariably sub-
side without  leaving any ill  effects  behind  them, we are
bound to hesitate before adopting a plan of treatment which
cannot  but  affect the strength  and ultimate  well-being of
our patient.   Even if a predisposition to cardiac inflamma-
tion be not engendered, as I believe it to be, by copious and
repeated bloodletting, still convalescence is  retarded, the
patient weakened and rendered liable  to frequent relapses.1
"Unde," says Sydenham, "non tantum eegrivires 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 venassection  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 irrita-
bility of the system, and favour 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 conse-
quences would result from the severity of the febrile disturb-
ance, then there would be no objection to the use of the
  1 This «*as 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.) 
76         TREATMENT OF ACUTE RHEUMATISM

lancet.  But the experience of all ages has proved beyond
dispute, that the febrile paroxysm is usually unaccompanied
by  danger; that  disorganization  of the joints very  rarely
occurs,  and supervenes as often, when  bleeding  has been
practised, 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 when  a treatment is adopted  in  which
phlebotomy has  its  share.   Mons.  Bouillaud,  the great
advocate  of copious  and repeated  venassection,  acknow-
ledges inflammation of the heart to  have been the rule, and
not the  exception in his practice : " Coincidence a peu pres
constante  soit  d'une endocardite,   soit d'une  pericardite
soit d'une endo-pericardite avec un  violent rheumatisrae
aigu."1  And  Dr.  Macleod, who  makes  no mention  of
the  frequency  of endocarditis, reports  pericarditis,  alone
in nearly one-fourth of his cases.  On the  other  hand, Dr.
Corrigan,  who rarely had recourse to bloodletting, observed
only one instance of it among many cases treated by opium;
and out of thirty-nine  cases in  my own practice,  it has
occurred but twice after the commencement of treatment.
  As, therefore, there is no absolute necessity for the use of
venassection, as it usually affords only temporary relief, and
as by the treatment hereafter to be mentioned, the pulse
may be  quieted, the pain allayed, and the fever and articu-
lar  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 persons, particularly in those which are  marked by
unusual severity of their symptoms, or are unaccompanied
by free perspiration,  and by other evidence  of activity in the
excretions.  Even in such  cases it should be  cautiously
employed, and carried to a small extent only, viz., from
eight to twelve ounces,  according to the age and strength
of the patient, the object being to favour the action of other
remedies, and  to  promote  free  secretion,  rather  than to
1 Op. cit., Preface, p. ii. 
OR RHEUMATIC FEVER.
77
arrest or  cut short the  disease.1   In the recurrent disease,
venisection, even  to a moderate  amount,  is  always  unat-
tended by benefit, and is sometimes followed  by dangerous
consequences ;  in mild cases it is unnecessary, and therefore
to be avoided ; in the delicate, or  in those of a weakly con-
stitution,  it  is  clearly  inadmissible;  and  in the strongly
predisposed,  or when the  disease  is hereditary,  it  utterly
fails  in  modifying  the  morbid action, is  often  ill borne
by the system, and therefore should seldom be practised.2
   1  I am glad to quote in confirmation of my opinion the testimony of that
 able and experienced physician, Dr. Latham.   After discussing the expedi-
 ency of having recourse to it, he adds, "summarily, then, 1 would venture
 to say  of venisection, employed under the most suilable 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 rheumatism.   It  very ofren renders the disease more curable by
 other means, but it seldom cures the disease  itself."   ('Clinical Medicine'
 vol i. p. 196.)                                                     '
   a  In confirmation of my opinion, as to the general inexpediency of bleed-
 ing,  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
 has  happened in a  second instance."   (Dr. Ileberden's ' Commentaries ' n.
 401.)                                                            l
   •'  Some practitioners continue to let blood in most cases  of rheumatism,
 thinking themselves justified on their mode of practice by the  sizy appear-
 ance of the blood.  The same principle might letd them to empty the whole
 sanguiferous system,  for  e\^ry time bloodletting is  repeated, the blood
 becomes more and more dense and sizy.  I have further observed, that by
 bleeding repeatedly, the pains, swellings, and febrile symptoms are not only
 aggravated  at the time,  but often protracted, indefinitely j  at  least, 1
 have seen them  continue  under such a mode of pi actice upwards of  two
 months" (Dr. Willan's 'Report on the Diseases of London.' p. 156.)
   " While it  was  the practice to  remove  the general inflammation  by
 bleeding, metastasis fiequenily took place to the interior paits of the body,
 and  destroyed the  patient.  This accident in  the author's practice  during
 the last fifteen years, has rarely happen*d.  In this period,  he has  entirely
 left off bleeding in acute rheumatism, and has  not lost above two or three
 patients, although he has treated several hundreds in this disease."  (Third
 Dissertation  on 'Fever,' p. 18, by Dr. Ford^ce, formerly Physician to St.
 Thomas's Hospital.)
   Dr. Alison '• has no difficulty in stating his conviction, that large and
rejeated  bleedings, in the beginning of rheumatism, increase  the  risk of
metastasis to the heart." and  that acute rhenmatii'm cannot, probably,  be
much shortened in its duration by antiphlogist'c remedies."   (• C\clop'_edia
of Medicine.' article ' History of Medicine,' p. 95.)
  " Excessive blcediDg, which has been another error in the treatment  of 
78          TREATMENT OF ACUTE RHEUMATISM
   When vensesection is employed in acute rheumatism, the
blood drawn is remarkably buffed  and cupped,  and  the
patient will  bear to lose a large  quantity  without fainting,
But neither of these facts is sufficient to justify the adoption
of the remedy, or to warrant its repetition.  The tolerance
of bloodletting 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,1  that  the
cupping  and buffing will continue  to the last,—will con-
tinue  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  diable
is audible in the large veins of the neck.
   In  conclusion,  then, without denying  the   occasional
efficacy of venisection in acute rheumatism, I seldom, very
acute  rheumatism, may  likewise protract the disorder."  (Dr. Francis
Hawkins, ' Gulstonian Lectures.')
  " It rarely happens, however, from the age of the patient, or the extreme
severity of the disease, that venisection 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 dailv habit of treating this disease, I
rarelv prescribe phlebotomy."  (Dr.  Watson's 'Lectures,' ed. 1,  vol. ii,
p. 625 )
  1 Messrs. Andral and Gavarret have clearly shown, that the increase in
the proportion of fibrin which rises in acute rheumatism, from 2 1-2 or 3
to 8 or 9, or  even 10.3 parts in 1000,  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 the frequency of the bloodlet-
ting,  and the amount of blood  taken. In  illustration of these facts,
I subjoin the result of four bleedings in three cases of acute rheumatism.
f Case i. Fibrin . . \ " ii. 1 " iii. C Case i. Globules . \ " ii. ( " iii.	Bleeding i.	Bleeding ii.	Bleeding iii.	Bleeding iv.
	6.5 5.4 6.1 114.8 125.3 123.1	6.2 7.0 7.2 111.0 124.9 120.7	7.0 6.1 7.8 102.8 121.4 112.8	6.9 5.41 10.2 88.7 99.6 101.0
  1 In Case ii, the pain and inflammation were subsiding at the time of the
fourth bleeding.  (' Annals de Chimie,' vol. Ixxv, pp. 240—48.) 
OR RHEUMATIC FEVER.
79
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 inflam-
mation  as rapidly as the most  copious  bloodletting; and
whether owing to peculiar bodily idiosyncrasies, or to other
causes equally beyond our ken,  the favorable  results  of
venisection  are so rarely met with, and  the  risk of evil
consequences incurred by its employment  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 nexts in im-
portance to  venisection.  The practice of  giving large and
repeated doses of calomel and purgatives  was first, I believe,
introduced by Dr. Chambers, and is  certainly most power-
ful 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
astonishment to those  who are familiar with the  features of
the complaint. 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 ami intestines throughout their whole  ex-
tent are stimulated to  inordinate action ;  the amount of fluid
excreted is vastly increased, and ,with it must necessarily be
evacuated a large quantity of the rheumatic virus.
   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 fol-
lowed by senna and salts in the morning. This discipline
ought generally to be repeated  on several successive dai/s."1
And Dr.  Hope, in the same strain, recommends  " calomel
and opium  at night, and a black dose every morning, suffi-
cient to ensure 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
1 On 'Rheumatism,' p. 34. 
80          TREATMENT OF ACUTE RHEUMATISM
means we possess of allaying the general febrile disturbance,
and of promoting the elimination  of the  rheumatic virus, I
must, nevertheless, express my dissent from the practice of
repeated  active purging.   And 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 his
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 expe-
rience,  inflammation  of the heart has supervened  imme-
diately  after the  exposure,  and the increase of irritability
consequent on  several successive  purging*, and more than
once I have been led to believe that this  unfortunate occur-
rence has resulted from the treatment adopted.  Accordingly
our constant endeavour should be to obtain a free evacuation
every morning, without  the risk and great discomfort attend-
ant 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,1  but by waiting some hours before ad-
ministering the purgative,  and thus giving the calomel time
to do its work, we  carry  off the excrementitious matters
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 not unfrequently happens 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  intestinal  derangement in a  very marked

  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 the
mucous membrane and glandular follicles of the  intestines, the  s-cretious
from  which are often mistaken for those of the liver.''  (Holland's 'Med.
Notes and Reflections ;' cup. on 'Mercurial  Aiedicines.') 
OR RHEUMATIC FEVER.
81
degree.  They complain of a sour and disagreeable taste in
the mouth, and of fulness and distension at the epigastrium ;
their conjunctivas 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  alto-
gether lost.   In these  cases there appears to be so much
torpidity of the primae viae, such an absence  of healthy in-
testinal secretion, and withal, probably, so  large an accumu-
lation in the system, of matter,  which 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 accompanied by signal
relief.   The  aperients, though  administered  in  full doses,
produce no griping, no tenesmus, no appreciable distress; on
the  contrary,  they are followed by copious, dark-colored,
offensive dejections, the  getting rid of which is evidently
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 his  tongue, the absence of the previously existing  fetor
of his  breath,  and the marked improvement of his  general
symptoms.
  Thus, then,  whilst 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 ex-
tremely, prejudicial to the safety of the patient.  In cases
unaccompanied by  those  indications  of intestinal derange-
ment before alluded to ; in cases in which the bowels are
acting freely, and the dejections are healthy and bilious  in
appearance, purging may be useful as a powerful means  of
drawing off the  poison, but it  certainly is unnecessary for
the cure of the disease,1 and must not be expected to afford
the relief observed to follow its  action in those cases which
especially call for its employment.  Indeed,  as already stated,
observation would lead to  its being reserved for exceptional
cases.   If there be much intestinal derangement, a cure can
  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 consti-
pated at the commencement of the attack, may be not only safely, but with
benefit, not disturbed more than once in two days."  ('Dublin Med. Journal,'
vol. xvi. p. 266.)
6 
82
TREATMENT OF ACUTE RHEUMATISM
 hardly be effected without it; but if there be not, the dis-
 comfort 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 venaesection and purging, has
 been  most frequently employed in acute rheumatism, is
 opium.  The symptoms of the disease are  so strikingly indi-
 cative of irritation and excitement, and are accompanied by
 pains  so  constant and severe, that the tranquillizing influ-
 ence 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  bloodletting,
 and acting from  time to time upon  the bowels by calomel
 and salts  and senna.  This method  of treatment is  objec-
 tionable, both on theoretical and practical grounds;—theo-
 retically,  because it is not conducive to the elimination of
 the  rheumatic poison ; and  practically, because it fails in
 materially alleviating the  patient's  sufferings,  and in short-
 ening 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 rheumatic in-
 flammation ; 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 alleviating his sufferings; and  if this medi-
 cine is to  be made  available for relief, it must be given to
 adults  in much larger doses.
  Dr.  Cazenave, of Pau,  was the  first  to recommend the
 exhibition of large and repeated doses of opium for the cure
 of acute rheumatism; but  the physician to whom the pro-
 fession 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 
                  OR RHEUMATIC FEVER.                83

until  the disease is steadily declining."1  The average quan-
tity required in twenty-four hours, he considers to be about
twelve  grains ;  and even  that quantity does not affect the
head.   Diarrhoea,  he  says,  sometimes  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 manifest
relief.
   Of this method of treatment I cannot speak from personal
experience,  inasmuch as, by  employing other medicines  in
conjunction 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.2  In the early and most painful stage
of the disease,  occurring in  adults, it may often be 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  slightest 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 illness.  More than this, too, I believe it has effected.
I  am satisfied that in many instances it has materially has-
tened the period of convalescence, and has lessened  the fre-
quency of inflammation of the heart.   Therefore, whilst I
join issue with those who  would treat acute rheumatism by
opium alone,  I admit  most  fully the advantage of  its  em-
ployment in conjunction with other remedies, and in quan-
tity  sufficient  to allay or subdue the pain.  The  amount
required for this purpose varies in different cases, and is de-
pendent not only upon peculiar  idiosyncrasies, but on the
severity of  the disease  in  each particular instance, and the
  1 ' Dublin Medical Journal,' vol. xvi.. p. 266.
  a '* 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 fulfilment of the purpose for which it is givenP  (Hol-
land's  ' Medical Notes ;' cap. ' On the use of Opiates.') 
84         TREATMENT OF ACUTE RHEUMATISM

treatment  previously and contemporaneously adopted.   In
cases where  opium is employed alone, about  twelve grains
may probably 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
continuance  of pain  is the best practical test of the pro-
priety of its administration and of the extent to which its
exhibition  is  required, 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  continue.1  I know  of  nothing to contra-
indicate 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 superven-
tion 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 ope-
ration carefully watched;  and observation has  convinced
me that it  suspends  secretion in exceptional cases only.
Indeed, it appears probable that opium, when given in quan-
tity sufficient to  subdue the pain and allay the irritation, so
far from impeding or suspending secretion,  conduces in some
instances 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 aiid imper-
fectly ;  the scanty urine, the dark coloured unhealthy mo-
tions,  and the  coated tongue, testily 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 a better plan
  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 va^ue the
expression, 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 appears in such instances to be wanting,
or produced chiefly in effect of the relief from suffering"  (Ho'land's
1 Medical Notes;' cap. (On the use of Opiates.')         °"   v 
OR RHEUMATIC FEVER.
85
than the treatment by purgatives, if the bowels have been
acting regularly and still continue to do so; but  the treat-
ment by purgatives is the most efficient and  most certain, if
the bowels have been previously bound and still show a dis-
position to be confined.
  Venaesection, then, calomel combined with purgatives, and
opium, are the  three remedies which have been most gene-
rally 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 dis-
ease before detailing my method of treatment.  I allude  to
vapour and hot air baths, and to mercury, antimony, cin-
chona, colchicum,  guaiacum, nitre, lemon juice, alkalies, and
their salts.
  Forced perspiration has always been much in vogue as a
remedy for acute rheumatism.  Formerly, though actually
steaming 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 sudo-
rifics ;  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
sudorem," the  unhappy sufferer has been sweated quite  as
freely; vapour and hot air baths have been substituted for
the extra bed-clothes and hot bottles, and guaiacum, 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 mattrass, 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  experi-
ences a relapse, and is generally subject for a considerable*
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 perspiration.  In such cases, and in such alone, it may 
 86        TREATMENT OF ACUTE RHEUMATISM

 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 sali-
 vation.  In my opinion, however, this practice is not only
 unnecessary, but decidedly prejudicial to the well-being and
 safety of the patient.  When given so as  to  affect  the
 mouth, mercury proves exceedingly depressing, and is some-
 times productive of evil  consequences which may be felt for
 weeks, months, or  even  years.  Moreover, it exerts no per-
 ceptible 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,1
 "that  the rheumatism has continued, although the mouth
 was affected, while it has speedily subsided on continuing
 the narcotic and purgatives without the mercurial."   More-
 over,  pericarditis #and endocarditis  supervene as readily
 whilst  the  patient is under the  influence  of mercury as
 when  that drug  has not been administered, and when such
 is the case, we lose  the most  valuable property of mercury,
 namely, that of limiting the effusion of lymph on the in-
 flamed  surfaces of  the heart.  Such  being  the case, mer-
 curial  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 efficacious  than in
 articular rheumatism.  The  medium   duration of the dis-
 ease, under the influence of this  remedy, is from seven to
 eight days; and we know that it continues from one to two
 months under the treatment of bleeding, or of ' la methode
 expcctante.' "2
  Now, admitting most fully the  efficacy of this medicine
 as an  auxiliary to other  remedies, I cannot  recommend its
 administration by itself as a remedy for acute rheumatism.
 Valuable as are its  powers in moderating  local action, it is
insufficient of itself to fulfil  the conditions essential to a
1 On ' Rheumatism,' p. 360.
J • Traite des Maladies des Poumons et du Cceur,' ed. 2, p. 502. 
OR RHEUMATIC FEVER.
87
safe and speedy cure of the disease.  And not only so.   More
extended  observations have not tended to verify the extra-
ordinary 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, whilst eulogising its power of subduing
the  articular  inflammation  and effusion, suggests that it
acts by " promoting  the activity of the interstitial absorp-
tion, more especially  when there exists in  the economy an
excess of energy of  tone or of plethora."  Whatever its
mode  of action, however, its efficacy is certainly 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 obviate  the necessity for bleeding  or
other  anti-phlogistic  measures, it may be employed in con-
junction  with  remedies having more  decidedly  curative
properties.   But  to  the  more weakly, and to those whose
symptoms are less acute, it often proves extremely depress-
ing,  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 con-
trary alike  to analogy and to experience.  It is inconsistent
with  the  active  nature of rheumatic inflammation; it is
contra-indicated 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
in the symptoms which usually follow its incautious exhibi-
bition.  It  has  nevertheless  been so well spoken of by men
whose recommendation  is  deserving of attention,1  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
  1 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.
Fothergiil. Dr. Ileberden, Sir George Baker, Sir Walter Farquhar, and
other physicians of experience and reputation. 
 88        TREATMENT OF ACUTE RHEUMATISM

 four times a day.  He generally began to give it between the
 third and the tenth  day of the  attack, at a  time when the
 articular inflammation 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  effects on its first exhibition."1   No opin-
 ion 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 experience.   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 rheumatism  which
 he has recorded,  49 were treated by salines, antimonials,
 purgatives, and bleeding, whilst the remaining  121 were
 treated more or less completely by  bark.   Out of  the whole
 number, 192 had symptoms of "phrenitis" and  "  delirium,"
 and of these 19 cases, no less  than  17 were met with among
 those  to  whom the  cinchona was  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
 administered by others ; but I have repeatedly watched its
 administration 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, or has dropped its sediment, the pulse  has  become
 soft, and the tongue moist and almost clean.  Then, more
 especially in cachectic states of constitution, or in  those who
 have been much exhausted by  the attack, it is often of essen-
 tial service; but even under these circumstances its effects
 must be carefully watched, in  order that its administration
 may be at once abandoned should any increased heat of skin,
 acceleration of the pulse, or coating  of the tongue or load-
ing 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

  1' Clinical History of Disease,' p. 108.
  • In column ix.  of Dr. Haygarth's tables, sixteen cases only are men-
tioned, but three others are to be found in column xvi. 
OR RHEUMATIC FEVER.
89
great majority of instances quina is more readily and earlier
tolerated ; and as it is quite as efficient as bark, it should
certainly have the preference when the eruption of sudamina,
the character  of the pulse, or the cleaning of the  tongue,
appear to demand or to admit of the exhibition of a tonic.
It should be used as a corrective and restorative of the  pro-
cesses of assimilation when the febrile paroxysm is beginning
to abate, rather than 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
exclusively relied on for its cure ; and in proof of its efficac}",
cases have been adduced in which the symptoms of the dis-
ease has not only disappeared under its influence, but their
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
favour 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 effect a cure;  but few,  I
think, are disposed to ascribe to it a curative power, except
under these  conditions.   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 when it be-
comes a question whether the cure of the disease  can be
safely intrusted to  colchicum alone, the prudent 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 rheum-
atism, it has at least the property of alleviating its symp- 
90
TREATMENT OF ACUTE RHEUMATISM
 toms,  and shortening  their duration.  It does so, I believe,
 not by operating  simply as a  sedative,  nor by acting spe-
 cifically upon  the rheumatic virus, but by promoting its
 evacuation by the kidneys, and by exercising some influence
 over the process  of assimilation, 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 frequently obtained by its
 administration uncombined with other remedies, and in doses
 insufficient to  produce any sensible effect  upon particular
 organs, that no one can hesitate to assign to it the improve-
 ment observed in the instances alluded to.
  But it is not equally beneficial in all cases of acute rheum-
 atism,  nor in all forms nor tat  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
 advantageous 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 most care-
 fully watched.  Throughout its administration it is impossi-
 ble to insist  too  strongly upon the necessity of securing a
 daily evacuation from  the bowels, and of attending to the
 other general symptoms of the disease.   If the lithates dis-
 appear from the urine,  if the pulse  becomes weak, if faint-
 ness, or  nausea, or purging supervenes, its use  must  be
 instantly discontinued.   But until some one of these symp-
 toms occur, 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  safely  and with
 advantage administered 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
 prescribed  it on several  occasions with some apparent ad-
vantage.   Observation, however, has not led me to form a
very favorable estimate of its curative power in this particu-
lar  form of the disease.   In persons  of  a  weakly broken- 
OR RHEUMATIC FEVER.                91
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 it has done no harm, it has
effected little good as compared with other medicines :  it has
neither appeared to mitigate the  symptoms, nor to shorten
their duration.
   There is, however,  as much  difference  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 mistura 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."1  Now, in my experience, the beneficial effects
of guaiacum  in the  acute  disease  are observed  precisely
under the conditions pointed out by Dr. Seymour:  they are
obtained in those  cases, and in those alone, which are unac-
companied  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 employ-
ment.   It  neither  modifies  the local  action nor limits its
duration ;  and as the purging induced by its  operation is
sometimes most distressing, its exhibition should be reserved
for subacute or lingering cases, in which, when  it  provokes
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 quan-
tities I have frequently given it in combination  with  other
remedies; and on several occasions I have seen it administer-
ed 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.
  1 C'inical Lectures, published in the ' Medical Gazette' and the ' Medico-
Chir. Review,' vol. xxxiii. 
92
TREATMENT OF ACUTE RHEUMATISM
   Mons. Gendrin in France and Dr. Basham in this country
 have lately been adopting the practice recommended by Dr.
 Brocklesby in 1764,1 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 Pitie.  He states that  the salt, when properly adminis-
 tered,  " is from the first tolerated  in the great majority of
 cases," but that sometimes " the injection of the solution oc-
 casions 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 some-
 times 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."2  Dr. Basham also speaks highly
 of its value when freely administered.   " 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  producing 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 vomitim>-.3  In a few cases
  1 ' Medical Observations,' by Dr. Richard Brocklesby, 8vo ; London, fyGl
The Doctor states, " that for diet and sustenance, the patient should be con-
fined to the free use of water-gruel, in each quart of which two drachms °f
nitre were to be dissolved, and when the stomach would allow the quantity
of drink, two drachms or more of nitre would be taken in the four-and-
twenty hours.  It usually caused free perspiration, and acted sufficiently as
&d ja?»nent) and when [t failed iQ this resl)cot) the he!p of injections was

  a On the Treatment of Acute Rheumatism by  large doses of NHtrate of
Potash.  (: Lancet,'for 1844, vol. i, p. 374.)
  3 Such symptoms nevertheless do sometimes occur. Dr. Robert Barnes
reports, that " in one case which he watched in the wards of M  Gendrin
alarming diarrhoea supervened on the second day together with' vomiting
and pain on pressure over the region of the stomach, and increase of febrile
movement."  (' Lancet,' for 1844, p. 472.) 
OR RHEUMATIC FEVER.
93
pinching or griping pains of the abdomen, with a few watery
evacuations, which have quickly ceased on discontinuing the
salt, are the only unpleasant or undesirable effects which he
has witnessed."1
  Now I heartily wish I could confirm this favourable report
of the  curative action of nitrate of potash, but such  unfortu-
nately 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 decid-
ed control 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 ordinary 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 tit home, the average duration of the cases alluded
 to  can hardly have been less than five or six weeks, which is
 certainly  a period of quite the average  duration.  But as
 nitre, contrary to the observation of Dr. Basham, docs appear
 to exercise a powerful  influence over the vascular system,2
 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 rheuma-
 tism,  not  so  much  by effecting  a cure of the  disease, as by
 tending to prevent those untoward complications which ren-
 der it so formidable.
   Lemon juice, in one or two ounce doses, repeated three or
 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 favours its ex-
 cretion from the system, while the small quantity of alkaline
  1 On the Nitrate of Potash in Acute Rheumatism.  (' Med.-Chir. Trans.,'
vol. xxxii. pp. 5 and 6.)
  2 Mr. Alexander found by experiment that nitre most surprisingly and
most  rapidly diminishes the frequency of the  heart's pulsations.  (Vide
1 Essays,' p 105. et seq.) 
 94         TREATMENT OF ACUTE  RHEUMATISM

 citrate which it contains, contributes also in some measure
 towards effecting a cure.  Whatever its mode of action, how-
 ever, 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 Piees,
 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-two patients, and al-
 though in several it produced  much depression,  in some
 griping pains in the abdomen, and in one gave rise to violent
 diarrhoea, 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 for as I could judge, was speedily converted
 or assimilated in the stomach; and  its influence in  quieting
 the heart's action,  in promoting a free evacuation from the
 kidneys,  and in causing subsidence of the articular inflamma-
 tion, was very marked.   But in most cases it  did not appear
 to be readily converted in the stomach, as was evidenced by
 the length of time which elapsed before the patient became
 free from its flavour ; and this, perhaps, may  account for its
 frequent  failure in  alleviating the symptoms of the disease.
 Be this as it may, the results of its administration were any-
 thing but encouraging.  And on analysing the cases reported
 by Dr. Bees, 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.  Therefore,  without denying that  lemon juice
may, in some instances, prove beneficial, I would not gene-
rally recommend its employment.   If alkalies and the neu-
tral  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; 
OR RHEUMATIC FEVER.
95
but it is less efficacious in curing the patient, and relieves
his sufferings far less  certainly and speedily than  docs  the
treatment I ordinarily pursue.
   Of the value of alkalies and their salts in acute rheuma-
tism, it is impossible to speak too highly.   Whether regard
be had solely to the facts that the normal alkalinity of  the
saliva  disappears, that the  acidity  of  the perspiration is
excessive, that 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  the
excretions,  but they are, in a great measure, preventive of
the deposition of fibrin.1  Administered alone, however, and
in ordinary  doses, they are quite inadequate to effect a 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 fail to arrest
the  disease  from being  unequal  to prevent the further
formation of acid in  the system.  Of this I am fully satisfied
by experience.  The  pain may  be greatly alleviated, and
the force of the febrile and inflammatory symptoms  checked,
but the disease will rarely be arrested or  shortened in its
duration without the addition of other medicines.
   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 bloodletting or opium,
or calomel and active purging, are necessary ; there may be
circumstances which call for the exhibition of guaiacum, of
nitre, of 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 disease presents
different aspects in different cases, so does it also at different
  1 See Simon's  'Chemistry,' in 'Sydenham Society's Publications' pp.
110,-17. 
96        TREATMENT OF ACUTE RHEUMATISM

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
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,  calomel, and opium.  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 bloodletting.  Baths are
never employed  if the skin is acting freely; but if, instead
of being bathed in perspiration, it remains dry and hot, and
burning, I then endeavor to stimulate its action by means
of the vapour or the hot air bath.
  As venisection, if employed  at  all in acute rheumatism,
is to be made use of with the view of producing an impres-
sion 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 tranquillization 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 secretion is insuffi-
cient, whose  pulse  is full and bounding, and  whose skin is
dry and hot,  and burning, it certainly does assist  in expe-
diting 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
congestion 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 givin^ 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 a dose of calomel and opium may be prescribed 
OR RHEUMATIC FEVER.
97
with the view of modifying the character of their secretions.
If the bowels are sluggish in their action, and the dejections
dark  coloured 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, together  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.
   AVhen  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 dejec-
tions dark coloured and offensive, the mercurial and the
purgative should both 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 charac-
ter, 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.
   Whilst the  state  of the  intestinal  secretions are  thus
 attended to, alkalies or  the neutral salts should be  admin-
 istered in combination with  colchicum, full doses of opium,
 and  sometimes a little antimony.  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.1   In  large  but
 ordinary doses they generally  mitigated the severity of the
  1 Though I speak throughout of the administration of alkalies, I gen-
erally prescribe the potassio tartrate of soda, which, readily undergoing
decomposition in the stomach, acts quite as energetically as corresponding
quantities of the alkaline carbonates, and  is much more readily tolerated
by the stomach.
                            7 
98          TREATMENT OF ACUTE RHEUMATISM
symptoms, yet failed in affording more than  partial relief,
but when they were exhibited in sufficient quantities, and in
combination  with other remedies,  the most agonizing  pain
was speedily removed, and the fever subdued with marvellous
rapidity.    I have, therefore,  ever since administered them
largely, and  have  pushed  them until my  object  has been
attained.   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 favor-
able results.   The patients have speedily  lost their pains
and have proceeded rapidly to  convalescence.  In twenty-
three out of thirty-nine  ones in my note-book,  the pulse
was tranquillized within  forty-eight  hours  from  the com-
mencement of treatment,  and in twenty-eight the pain was
lulled,  and the local inflammation greatly subdued  within
the  same time,  whilst  in  the  remaining  cases  a  longer
period  was  required,  in consequence either  of previous
constipation,  or of the co-existence  of some internal com-
plication.
  The  form in which I usually administer the remedies,  is
that of a simple  saline or a nitre draught, to  which, if the
patient be a  person of  average  strength  and robustness,
bathed in profuse perspiration, with red,  swollen,  and ex-
quisitely  painful  joints, a furred tongue, loaded  urine, and
a full and bounding pulse,  I  usually add from two to three
drachms  of  the  potassio  tartrate  of soda,1  ten  or  fifteen
  1 The virtue of alkalies and their salts in rheumatism depends, I believe,
upon their power.
  1st. Of acting as restorers of all the alkaline condition of the system.
  2dly. Of assisting to maintain the solubility of the fibrin, and thereby
preventing its deposition on the valvular apparatus of the heart.
  Odly. 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
provocatives of an increased secretion of urine, whereby the elimination of
the materies 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 inflammation, 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 augumentation  in its solid constituents. These facts
receive very striking illustration in the cases reported at the end of this
Chapter. 
OR RHEUMATIC FEVER.
99
minims of the vinum colchici, from fifteen to twenty minims
of the vinum antimonii, and from ten to fifteen minims  of
the tinctura opii, or of Battley's sedative solution, to prevent
the salt running off by the bowels. This draught is repeated,
for the first twelve  or  twenty-four hours, at  intervals  of
three or four hours, according to  the strength of the patient
and the severity of the attack ; 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 equivalent dose of Dover's
powder to be taken once or twice a day, taking care to in-
crease 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, guarding against
diarrhoea.
   Sometimes, though rarely, the stomach does not easily
tolerate these large doses of the neutral  salts,  and in such
cases, the greatest benefit is derived from the addition of a
little lemon juice and an alkaline carbonate, forming a saline
effervescing draught.  With this  variation an instance rarely
occurs in which the medicine  deranges the  stomach,  or
produces the slightest disagreeable effects.
   When once the medicine has begun  to take effect, which
is evidenced by  the  gradual decrease of the pain, the tran-
quillization of the pulse, and  the increase in the quantity
and specific gravity of the urine ; it is repeated  every fourth
hour only, and  then every fifth  or sixth hour;  and usually
at the expiration of two or three days, I find its work in
great measure accomplished:  the saliva,  by that time has
lost its acidity,  the pains and  inflammation have subsided;
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,  less loaded with the lithates,
and of a higher specific gravhvy; and the perspiration less acid,
less sour smelling, and less profuse.   In proportion as these
syuqrtoms 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 administra-
tion of quina during  the day, 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, toge-
ther with aloes or rhubarb, and  if necessary, a grain of calomel
or blue pill.  Should there be the  slightest return of pain,
the least increase of coating on the  tongue, or, indeed, any 
100        TREATMENT OF ACUTE RHEUMATISM
 evidence  of returning  fever, the use  of  quina 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 tendency  to  perspiration,  the mistura
 guaiaci of the Pharmacopoeia may be administered with the
 addition of a drachm of the volatile tincture  of  guaiacum,
 and twenty or thirty minims of liquor potassa',  whilst if the
 patient appears to  be cachectic,  the decoction of cinchona,
 with the addition of the ammoniated tincture of  guaiacum,
 or of half a drachm of  the  extract of sarsaparilla with two
 or three grains of  iodide of potassium, and twenty minims
 of liquor potassee, proves a more active and efficient agent.
   But  I  do  not confine  myself to internal remedies.   I
 endeavour 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
 affected rheumatic 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 hazardous  experiment  would be
 tried  and serious internal mischief  wTould  probably  arise.
 But  against leeches, blisters, and warm fomentations, this
 objection cannot be reasonably urged : they do not check the
 continuance of perspiration ; they favour 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
 curat ive power.
  It has been already stated, that rheumatic inflammation very
 rarely leads to disorganization  of the joints, and moreover
 displays 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
the relief of the inflammation, and are useless in most cases,
because of its repeated migration.  They might, and indeed
they do, afford very marked relief to the severity of the in-
flammation, but they afford  no  guarantee against  its recur-
rence.   Their use,  therefore, should  be  restricted to those
 cases in which inflammation lingers about a particular joint, 
OR RHEUMATIC FEVER.
101
or in which the intensity of  the action is  so great as to
threaten the integrity of the structures.  But warm foment-
ations of every description may be always employed advan-
tageously.   They soothe the parts, promote perspiration, and
thereby favour the elimination of the poison.   As the object
of the applications is to allay the  pain, and to 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 effective 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 far
the most powerful in allaying the pain of rheumatic inflam-
mation.1  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  effect  observed to follow these  saline fomenta-
tions has not been due to accidental causes, is manifest  from
the result of careful experiment; for in order to guard against
any source of fallacy, I selected fourteen instances in which
corresponding joints were affected, and applied a fomentation
of warm water to the one joint, and  an  alkaline and opiate
solution to the other, and almost uniformly the pain and in-
flammation continued in the former, and speedily subsided iu
the latter.   Besides this, I  have endeavoured to  ascertain
whether the  occurrence of inflammation  may not be pre-
vented  by impregnating the parts with alkaline matter.2  In
nine cases in which the knees, and in seven cases  in which
the hands were  in the first instance unaffected, a mixed  alka-
line and opiate solution was applied  to one joint, and a sim-
ple water fomentation to the corresponding joint on the other
  1 The solution I usually employ is Potassas Carb., §j, Liq. Opii sedativi,
3vj, Aqua; Rosa, fix.  Sometimes, however, I substiiute the Decoction of
Poppies for the Liquor Opii and Rose "Water.  Thin flannel soaked in  one
of ihcse mixtures should be  applied to the inflamed parts, and the whole
should then be Wrapped up in gutta percha.  Markwick's epiihem forms a
tolerably efficient substitute for the flannel and gutta percha.
   In a practical point of view, the determination of this question is not of
much importance; but  on theoretical grounds, as bearing upon the occur-
rence and possible prevention of cardiac  inflammation, it is  of the utmost
moment. 
102        TREATMENT OF ACUTE RHEUMATISM
side.  In four of the former cases, and in two of the latter,
the joint to which water only had been applied became in-
flamed, whilst in one instance only did inflammation occur,
and that to a very slight extent, in the joint which has been
bathed in an  alkaline and  opiate solution.1   So that my ex-
periments, though not as yet sufficiently 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.   Whilst attacking
the disease both by internal and external means, it is essen-
tial to pay strict attention to the diet.  The patient must be
kept low ;  yet, as there is an excessive  drain upon the sys-
tem, it is expedient 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 quantity ;
and with the view of supplying the waste caused  by the
perspiration,  and of promoting 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.
  The following cases will serve to illustrate  my plan of
treatment:
  Case i.—William Made,  a thin, pale,  unhealthy looking
boy, aet. 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 even-
ing of the same day had been  attacked with  shivering, suc-
ceeded 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, his right knee, his right 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, his
countenance distressed,  and  he  was  sweating profusely.
Tongue white  and furred.  Bowels  costive.   Urine scanty,
  1 I am indebted to the kindness of my colleagues, Dr. Wilson and Dr.
Bence Jones, for several opportunities of trying these experimeLts. 
OR RHEUMATIC FEVER.
103
high  coloured, and loaded with the 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 rheuma-
tism (V), 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 car-
bonate of potash in a pint of decoction of poppies ; his diet
was limited to beef tea, gruel, and arrow-root; and the fol-
lowing medicines were prescribed:
    ft, Hydrargyri Chloridi,
       Pulveris Doveri, aa gr. iij.  M. ft.  Pulvis statim sumendus.
   Ilaustus Sennse c. Sodae Potassio-Tart, 3 iij, post horas quinque.
        Haustus Salini, gjss;
        Sodse Potassio-Tartratis, 3 ij ;
        Vini Colchiei, 1H.xv;
        Tincturse Opii, Hlvij.  M. ft.  Haust. 6'* quaque hora sumendus.
   August  25th.—Passed a tranquil  night, though without
much sleep, and to-day is comparatively easy.  The redness
has  almost entirely disappeared, and the swelling has sub-
sided considerably.  Bowels acted on twice by the medicine
yesterday, and to-day have been freely moved once.  Per-
spiration still very profuse and acid.   Urine about 1£ pints,
besides what was passed at stool; acid;  less high coloured
and loaded ; sp. gr. 1031.   Tongue moist and much cleaner.
Pulse 9S, soft.  Heart's sounds clear.   Saliva still acid.
                  Rep. Haustus 6" quaque hora.
    ft. Pulv. Ipecac, comp., gr. x ;
       Hydrarg. Chloridi, gr. iij.  M. ft.  Pulvis hac nocte sumendus.

   26th.—Slept well last night;  to-day has neither redness
nor swelling of the joints, and slight stiffness 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 in die tantum.

   27th.—Passed another quiet night, and  has no return of
pain.  Bowels have acted once.  Tongue quite clean, except
just in the centre, where it is  rather  white.  Urine clear,
and  in  great abundance ; sp. gr. 1030.  Pulse 76, soft.  Is
up and about to-day. 
104        TREATMENT OF ACUTE RHEUMATISM
    ft.  Haustus Quina3 c. Acid Sulph. dil., flixv. Sulph. Magnesiae,  3s3,
            bis in die.

  From this time he continued taking the Quina until  the
30th, when having had no return of pain, and feeling quite
well, the medicine was discontinued.
   Case n.—Charles Birch, a strong muscular man, ast. 45,
was admitted into the Hope Ward of St. George's Hospital,
on the 30th of October,  1850.  He had  experienced two
previous attacks of acute rheumatism, the last of which was
about five years ago, and  continued in a subacute form for
three months after the acute stage had passed away.   The
present attack commenced with shivering, two weeks ago,
after exposure  to damp and  cold during the greater part of
three days.   Inflammation first attacked the knees and the
right hand  and wrist, in all  of which joints it was veiy
severe.  Its seat, however, had shifted repeatedly.
   The following were the symptoms on admission :—The
left  ankle, and both  hands and wrists, red, swollen, and
inflamed ; perspiration not very profuse, but extremely acid,
and  of the peculiar empyreumatic odour  of rheumatism;
conjunctivas yellow ; saliva acid ; tongue coated, and rather
dry  and red at the tip and edges ; bowels costive ;  urine
scanty, high coloured, and loaded with  the  lithates ; sp. gr.
1022.  Pulse 114, strong, full, and bounding.  Heart's action
regular: its sounds  free  from  murmur,  but its impulse
stronger, and more extended than natural.
   The inflamed joints were encased in flannel soaked in an
alkaline  and opiate solution;  and as the perspiration was
not  very free, I ordered  a vapour  bath to  stimulate the
action of the skin, and prescribed the following :

     ft.  Hydrarg.  Chloridi. g. v, Ext. Colchici Acet., Pulv. Ipecac, co.
             au gr. iij.  M. ft. Piluke duas statim sumendae.
     Haustus Sennas c. Soda3 Potassio-Tartratis, 3iv, post horas quinque.
         H. Potassoe Nitratis,  gjss ;
         Soda; Potassio-Tart., 3ij;
         Vini Antimonii. V[xx;
         Vini Colchici, itixij;
         Tincture Opii, mxij. M. ft. Haust. 4U quaque hora sumendus.
         Pulveris Ipecacuanha; comp., gr. x. nocte maneque.
  For diet,—beef tea, gruel, milk, and arrow-root. 
OR RHEUMATIC FEVER.
105
   October 31.tf.—Dozed for some time during the night, and
is  much easier this morning.   The pain and inflammation
shifted last evening to  the left knee and the right shoulder,
leaving the hands and wrists free from swelling, and almost
free from pain.   Perspired profusely in  the bath,  and still
continues to do so. Conjunctivae still yellowish. Bowels acted
twice freely after the Senna, and the tongue is moister and
less furred.   Saliva still acid.  Urine about fourteen ounces,
besides wrhat was passed at stool:  loaded with the lithates ;
sp. gr. 1027.  Pulse 96, and less bounding.  Heart's sounds
still free from murmur.
   He was ordered to continue the  draught, the powder, and
the fomentation, as before, and to take the following pills at
bedtime :

         ft.  Hydrargyri Chloridi, gr. iij ;
             Pulv. Ipecacuanhae,
             Ext. Aloes Aquosi, aa gr. ij.  M. ft. Pilula; duae.

   November 1st.—Passed a quiet night, dozing at intervals,
and is almost free from pain this morning.   The left knee
alone of all the joints remains swollen, and that only slightly.
It is not painful, except on sudden motion.  Still perspiring,
but not so freely as before, neither has the perspiration such
a strong acid odour. Conjunctivas clear.  Saliva very slightly
acid.  Tongue much  cleaner, and less  red.  Bowels have
acted more copiously.  Urine reported  about three  pints :
that which  has  been saved  is acid, with a slight deposit of
lithates; sp. gr. 1030.  Pulse 84,  soft.   Heart's sounds still
free from murmur.

  To repeat the vapour bath, and to continue the draught  and fomenta-
       tions, as before.
  The powder to be omitted.

   2d.—Slept well.  The knee no longer swollen,  and almost
free from pain.   Sweated profusely in  the bath, and has
perspired freely ever since.   Bowels have acted once, but
not copiously.   Conjunctivae  again rather yellow.  Tongue
cleaning.  Saliva slightly acid.  Urine about If pints, clear;
acid ; sp. gr. 1032.  Pulse  80, soft.  Heart's sounds free from
murmur.

       To repeat the medicine three times a-day.
       To take at bedtime the pills ordered on the 30th of Oct. 
106         TREATMENT OF ACUTE RHEUMATISM
  3d.—Slept well, and is quite free from pain and swelling.
Is up and  dressed to-day, and complains of being hungry.
Bowels have acted twice freely.   Tongue cleaning rapidly.
Saliva has an alkaline  reaction.  Urine about thirty ounces,
clear, very faintly acid ; sp. gr. 1031.  His skin still exhales
a rheumatic odour.
  As the salines appeared to have done their work, I ordered
the following:
*s
       ft.  Potassii Iodidi, gr. ii, Misturaj Guaiaci, 5jss. ter in die.
           Fish diet.                           '

  In the course of a few days his tongue cleaned ;  and the
slight remaining stiffness of his joints subsided.  On the 8th
instant he was permitted to have ordinary meat diet; and on
the 12th was allowed to leave the ward.  In order, however,
to guard against a relapse, I did not permit him to  quit the
hospital until the 20th.
   Case in.1—William  Connor,  a carpenter,  get.  31,  was
admitted a patient of the Pimlico Dispensaiy 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 form for a period of four
months.  The present attack commenced on the 12th instant,
and was ushered  in by chilliness, followed, in the course of
a few hours, by pain, heat, redness, and swelling of both his
wrists, his right elbow, and his left knee.  The inflammation
shifted rapidly from joint to joint, and when I first saw him
on  the Kith, 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
odour  of rheumatism, and standing in large drops upon hia
forehead.  Conjunctivae yellow;  tongue red at the  tip and
edges,  and coated in the centre with a thick yellowish white
  1 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. 
                   OR RHEUMATIC FEVER...              107

fur.  Bowels reported open ; urine scanty, dark-coloured, and
loaded  with  the lithites; sp. gr. 1025.  Saliva  extremely
acid.  Pulse 116, full and bounding.   Heart's action regu-
lar, but its impulse somewhat increased, and a loud systolic
mitral murmur, probably of old standing,  distinctly heard at
its apex.   No friction sound, and no prascordial pain.
   I ordered the joints to be fomented as usual; restricted his
diet to beef tea, milk, and gruel, and prescribed the following
medicine:
    ft.   Ilydrargyri Chloridi, gr. v; Opii, gr. ij.  M. ft.  Pilulte dua; horu.
           bomni  sumendao.
  Hau t. Sennae c. Soda. Potassio-Tart.'  3iv. eras primo mane  sumendus.
        Liquoris Potassse, fl\xl ;
        Potassse Tartrfitis, 3ij ;
        Vini Colchici, tt\x;
        Tincturae Opii, 1l\xij ;
        llaust. Potassse Citratis, gjss.  M. ft.  Iluust. 4'a quaque hora
           sumendus.

   17th.—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. 102S.   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.

   ISth.—Passed a  quiet nighty 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_r pints, 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 tuke the pills and Senna draught, as ordered on the 16th inst.

   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, 
 108        TREATMENT OF ACUTE RHEUMATISM

 and the urine is reported 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.

   20^.—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 abun-
 dant, clear, and acid ; sp. gr. 1.027.   Pulse 64, and somewhat
 weak.  Is up and dressed to-day, but feels very low.

  To omit the saline medicine, and take the following:
  ft.  Quina; Disulphatis. gr. ij ;
      Sulphatis  Magnesias, 3ss;
      Acidi Sulphuriei dil., 1Hv ;
      Tincluras Aurantii, 3jss;
      Aqua; distillatse, gjss. Ft. haustus bis in die sumendus.
      Haustus Sennas c. Soda? Potassio-Tart. 3iv, eras mane.
  Fish, and beef tea.

  From this  time he proceeded  steadily to  convalescence;
and on the 24th instant wTas so far improved, that he  asked
leave  to be allowed to resume  work.  He was induced, how-
ever, to take the  Quina for a  few days longer;  but on the
26th he felt so thoroughly well, that he betook himself to
his ordinary occupation.
   Case iv.—Michael Wood, a labourer, aet. 43, was admitted
into the York Ward of St. George's Hospital on the 4th of
September, 1S50, suffering  from acute rheumatism of one
week's duration.   He had never before experienced an attack.
He reported that he had been  languid and out of health for
some weeks, but had not been compelled to  give up work
until the 28th of August, when his left knee became swollen,
and then  in succession the right knee and  ankles, and the
left hand and wrist became red, hot, swollen, and extremely
painful and tender.
   When I first  saw him  after admission, the above-named
joints were inflamed: he was sweating profusely, and exha-
ling the strong acid disagreeable odour of rheumatism: his
conjunctivae were yellow, his tongue  was furred in the cen-
tre, and red at the tip and edges : the  saliva  was acid: bow-
els costive: urine scanty, high coloured, acid,  and loaded 
OR RHEUMATIC FEVER.
109
with the  lithates ; sp. gr. 1024.  Under the microscope, it
was seen to contain, in addition to the amorphous deposit of
the lithates, some few octohedral crystals of the oxalate of
lime.   Pulse 120, full and bounding.   Heart's action regular,
impulse normal, sounds clear and free from murmurs.  He
was unable to get a wink  of sleep, and had scarcely closed
his eyes since the beginning of his attack.
   I ordered  an alkaline and opiate fomentation to the in-
flamed joints, and prescribed the following :
  ft. Hydrarg. Chloridi, gr. v, Ext. Colchici Acet., gr. iii, Opii, gr. jss.  M.
         ft.  Pilulse dute statim sumendes.
  Ilaust. Senna? c. Soda? Potassio-Tart, 3 iij, posi boras quinque.
     Haustus Salini, gjss;
     Sodas Potassio-Tart., 3 ijss;
     Vini Colchici, 111 xvj ;
     Tincturze Opii, TUxij.  M. ft. Haust. 4'a quaque hora surnenda:.
     Pulvei is Doveri, gr. x, hora somni.

   Sept. 5th.—Passed a tranquil night, dozing at intervals.
The pain ia still considerable, but the redness has disap-
peared, and the swellings are much reduced.  No fresh joints
have been attacked.  Has not perspired very freely.   Con-
junctivas  yellowish.  Tongue  moister and  much  cleaner.
Saliva acid.  Urine reported about  2 pints.  It is  almost
clear,  acid ; sp. gr. 1028.   Bowels acted twice  after the
Senna yesterday, and have been once relieved to-day.  The
motions, however, are dark-coloured and offensive.   Pulse
86, soft.   Heart's action  regular, and its sounds  still free
from murmur.
   A vapour bath was prescribed, with the view of increasing
the action of the skin, and he was  ordered to  continue the
draught and fomentations, and to take the following pills at
bedtime :

    ft.  Ilydrarg. Chloridi, gr. v, Ext. Colchici Acct,, gr. iij, Pulv. Ipeca-
           cuauluc. gr. jss.   Misce.

   Ca'h.—Sweated profusely after the  bath, and experienced
much relief.   Slept during the greater part of the night, and
feels much better to-day.   The joints are  no longer swollen,
and he  now only complains of wandering pains in his back
and shoulders.   Not perspiring  freely now.   Conjunctivas
still yellowish.   Bowels  have  acted, but  not copiously.
Tongue moist, no longer red, and almost clean.   Urine about 
110        TREATMENT OF ACUTE RHEUMATISM

2} pints, clear, with a slight sediment of the lithates; pp. gr,
1029.  Pulse 76, soft.   Heart's action regular, and its sounds
clear and free from murmur.
  The vapour bath was ordered to be repeated; the draught
to be given only three times a day, and the following pills to
be taken at bedtime :
     ft.  Hydrarg. Chloridi,-
         Ptilv. Ipecacuanhae,
         Ext. Aloes Aquosi, aa gr. ij;
         Ext. Colchici Acet.. gr. iij.  M. ft.  Pilulre dua;.

  7tit.—^Sweated profusely in  the bath,  and  wTent  to sleep
soon afterwards,  and slept  quietly all night.   No return of
redness and swelling, and has only slight stiffness and fugi-
tive pains in the  limbs.  Not perspiring  much this morning.
Conjunctivas less yellow, but not yet clear.   Tongue clean-
ing rapidly.  Bowels have acted three times  copiously, and
the motions are no longer  offensive.  Urine about IJ pints
besides what was passed at stool; clear,  acid,  of a straw col-
our ; sp. gr. 1029.  Pulse  76, soft.   Heart's sounds remain
clear, and free from murmur.
  As there was still some stiffness, and the skin's action was
not very free,  the vapour bath  was repeated;  but I thought
it safe  to omit the saline, and  to  give him a quinine draught
twice a day, containing sss of Sulphate of Magnesia.
  From this time his convalescence proceeded steadily.  He
got up and dressed himself on  the morning of the Sth, and
remained about the ward during the day.  Once again the
bath was repeated  by way of precaution,  as  were also the
pills ordered on the 6th instant;  but  the Quina was contin-
ued as before, and a generous diet allowed.   Day by day he
got rid of his  stiffness,  and regained  his strength.  On the
16th, as he had been nearly a week free from rheumatism, it
was decided that he should leave the hospital on the 18th;
but incautious exposure to  cold on the 17th, induced a slight
recurrence of his symptoms, so that it was thought expedient
to have recourse again, for  a short time, to salines and vapour
baths.  Under their influence he got rid of the pain in a cou-
ple of  days; but as he had evinced  so strong a  tendency to
rheumatism, I thought it advisable to  keep him in the hospi-
tal until  the 2d of October. 
OR RHEUMATIC FEVER.
Ill
  Case v.1—Jane Arkwright, a strong and generally healthy
person, set. 23, applied for relief to the Pimlico Dispensary,
on the 19th of August, 1S4-5.  She had been seized on the
afternoon of the 11th instant, with wandering pains and fev-
erishness, which rapidly increased in severity, and caused her
to take to her bed.  In the course of the night her left knee,
and her right hand, wrist, and elbow,  began to swell, and
became so exquisitely tender that she could hardly bear the
weight of the bed-clothes.   The present was her first attack
of the disease.
  When I first saw her, both knees, her left elbow, and the
right hand and wrist  were  red,  swollen, and painful.   She
was not  perspiring freely, but her  whole body exhaled the
strong, peculiar, acid  odour  of rheumatism.   Tongue yellow
and furred.   Saliva very acid.  Urine exceedingly scanty,
and loaded with the lithates ; sp. gr. 1026.   Bowels reported
regular; as also the catamenia,  which had  appeared a  fort-
night previously.   Pulse 126, full and bounding.   Heart's
action regular;  sounds healthy.   She  had been unable  to
sleep since  the  beginning of the attack, and within the last
twelve hours had been harassed by a short hacking cough,
with pain, increased on inspiration, at the lower part of the
chest on the  right side.   The stethoscope gave  evidence  of
the commencement of pneumonia,  for the characteristic fine
crepitations were distinctly  audible over the base of the right
lung.  There was no  pleuritic friction or csgopliony.
  The inflamed joints were fomented, as usual, with an alka-
line and opiate lotion  ; and as she was a strong hearty person,
I bled her to ten ounces, and followed the bleeding by a pill,
containing  Autimonii Potassio-Tart., gr. J,  Opii, gr. j.   The
following medicine was also administered :

    ft. Ext.  Colchici Acet.. gr. ij, ITyd. Chloridi, gr. i j, Pulv. Dovcri gr. v.
            M. ft. Pilulte duse hora. somni sumendre.
        Ilaust. Senna; c. Sodae Potassio-Tart., 3iv. eras inane.
        Soda; Potassio-Tartratis,  3jss;
        Vini  Antimonii, 1J\xxv;
        Vini Colchici, 1t\xiv;
        Tinctunc Opii, utxj ;
        A qua; distillatse,  sjVs. M. ft Ilaust. 4ia  quaque hora sumendus.
      Cataplasma Sinapis Latcri Thoracis dextro.
  Broth diet.
  1 I am indebted to  my friend Dr.  Fincham, formerly Physician to the
Pimlico Dispensary, for the opportunity of seeing and treating this case. 
112         TREATMENT OF ACUTE RHEUMATISM

  August 20th.—Did not  experience much  relief from the
bleeding, but broke out into  a free  perspiration soon after-
wards, which has continued  ever since.  The blood drawn
was highly buffed and cupped.  Passed a tolerably tranquil
night, though without sleep.   No fresh joint has been attack-
ed ; but the pains are not much easier, and the swellings are
almost as great as before.   Tongue furred, but less red than
yesterday.   Saliva very acid.   Bowels have acted twice since
taking the Senna.  The motions are dark-coloured, and offen-
sive.   Urine  reported  still scanty,  and excessively loaded;
none, however, has been saved for examination.   Pulse  112.
Heart's action regular, and sounds still free from murmur.
Less cough  and pain in the  chest, and no extension of the
crepitant ronchus.
               Repetatur haustus 4ta quaque hora.
               Repetatur Cutaplasma Sinapis.
   ft. Hydr. Chloridi, gr. iij, Antimonii Potassio-Tart.. gr. £,  Opii. gr. ij.
          M. ft. Pilula; dure  hora somni sumendse.

  21s?.—Has  passed a quiet night, dozing at  intervals, and is
much easier to-day.  Joints no longer red, and less painful,
but still much swollen.  Is perspiring freely.  Tongue coat-
ed.  Saliva still acid.   Bowels have not acted.  Urine about
l£ pints ; less turbid ; acid ;  sp. gr.  1030.  Pul r-e 9S, softer.
Heart's action regular, and its sounds as in last report.   The
pneumonic crepitation  is  disappearing, and giving way to
healthy respiration.   There is no longer any pain in the right
side.
               Repetatur haustus 4ta quaque hora.
               Repetantur pilulaa heri pro.-cnpt_e hora somni.
         Ilaust. Senna; c. Soda; Potassio-Tart., 3iv.,cras mane.

  22J.—Slept soundly for four hours, and dozed at intervals
besides.  Feels easier and better in every respect.  Joints
far less  painful, and swollen.  Still perspires freely.  Tongue
no longer red, but still  covered with a  white coating in the
centre.   Saliva acid.  Bowels have acted twice  copiously.
No urine saved;  reported almost clear.   Pulse  86, much
softer.   Heart's  action regular, and  sounds normal.   No
longer any cough, or any auscultatory signs of pneumonia.
               Repetatur haustus ut antea.
               Pulveris Doveri, gr. x, hora somni.

  23d.—Passed a tranquil night, sleeping altogether about
six hours.   Joints  no  longer swollen,  but still stiff and 
OR RHEUMATIC FEVER.
113
painful.  Perspiration continues profuse.   Tongue cleaning
rapidly.  Bowels  have been moved once, but not freely;
the  dejections are  of a  natural  colour.  Urine  in  great
abundance, (about 3 pints,) clear, acid; sp. gr. 1029.   Pulse
80, soft.   Heart's sounds clear; respiratory murmur natural.
Feels very low.
         Repetatur haustus ter in die tantum.
         Repetantur Pulvi. Doveri, gr. x, hora somni.
II. Semite c.  Soda; Potassio-Tart., 3ij, eras mane, nisi prius responderit
    alvus.
   24fA.—Slept soundly all  night, and  is  almost free from
pain to-day.   Has  ceased to  perspire  profusely.  Tongue
almost clean.  Saliva no  longer acid.  Bowels did not act,
so  she took the Senna draught, which has operated  freely,
Urine about  the  same   as yesterday.   Pulse  76,  weak.
Heart's action regular; sounds  normal.   Complains of feel-
ing very weak and low.
                    Omittatur haustus salinus.
      Haustus Quina;, gjss, c. Acidi Sulph. dih, Ttixv, ter in die.
Fish, and beef tea.

   25th.—Passed  another  good  night, and is up and dressed
to-day.  No recurrence of pain, and complains only of weak-
ness and slight stiffness in  her left knee.   Tongue moist, and
almost clean.   Bowels  have  been relieved once to-day.
Urine abundant, clear, acid; sp. gr. 1028.   Pulse, 76.
      Repetatur haustus Quinse, ter in die.  Ordinary meat diet.

   From  this  time  she   gradually regained  her  strength*
Twice I thought  it  expedient to give her  a pill at bedtime,
containing 1 grain of blue pill, 2 grains of the acetous  ex-
tract  of Colchicum, and 2 grains of Aloes; but  with these
exceptions  she took nothing  except the  quinine draught,
which she finally omitted  on the 31st instant.
   Case vi.—James Blizzard, set. 22, was admitted  into the
Fitzwilliam Ward of St. George's  Hospital on the  9th  of
August,  1851.  He had  caught cold eighteen days  previ-
ously, whilst heated from  hard work.  No shivering took
place, but he lost his appetite, perspired profusely, and was
oppressed by a sense of lassitude.   After nine days, general
                    8 
114         TREATMENT OF ACUTE RHEUMATISM
 feverishness ensued, and most  of the larger joints became
 inflamed.   From that  time he  had been unable  to  sleep.
 The present is his first attack.
   When I first saw him after  admission, his hands, wTrists,
 and right knee  were swollen, hot and painful,  and there was
"considerable effusion into the knee joint.   He was not per-
 spiring  freely.    His  conjunctivas were  yellow.   Tongue
 coated,  and rather  dry.   Saliva  acid.   Bowels  reported
 open.  Urine scanty,  high  coloured,  and loaded with the
 lithates; sp. gr. 1019.   Pulse 116,  full, and bounding.
 Heart's action regular; its sounds clear.
   As his pulse was full and forcible, and secretion sluggish,
 I had him bled  from the arm to the extent of  8 ounces; his
 joints were fomented with an alkaline and opiate fomenta-
 tion, and the following medicine was administered:

    ft.  Hydrarg.  Chloridi, gr.  v; ext. Colchici  Acet., gr. iij ; Pulv.
           Ipecacuanha?,  gr.  ij.  M. ft.   Pilulse dua? hora  somni
           sumendae.
        Haustus Sense c. Soda? Potassio-Tart.,  3iv, eras  mane.
        Haustus Potaseae Nitratis, gjss ;
        Sodas Potassio-Tartratis 3ij;
        Vini Colchici, 1t(x;
        Tinctura? Opii, ntxv.  M. ft. Ilaust. 4'a quaque  hora sumendus.
  Broth diet.

   August 10th.—The blood drawn was  not puffed or cupped,
 owing probably to the smallness of the stream in which it
 flowed.  Immediately after the operation, however, he broke
 out  into a  profuse  perspiration, which has continued ever
 since.   The  perspiration is extremely acid, and  smells very
 sour.  Tongue coated, red, and still rather dry, though less
 so than yesterday.   Bowels have acted freely.   Urine report-
 ed very scanty;  that which has been saved  is very  high
 coloured, loaded with the lithates, sp. gr.  1023.  Pulse 100.
 Heart's sounds remain clear,  and its action regular.
                Repetatur haustus 3tia quaque hora.
                Opii, gr. i, hora somni.

   ll^A.—No sound  sleep, but dozed during the nio-ht.  Is
not much easier this morning, but no fresh joints have  been
attacked,  and  the  former swellings  are  greatly reduced.
Tongue much moister, and cleaner.   Saliva still acid.  Bow-
els have acted freely.  Urine reported about 1£ pints.  It is
acid, clear, with a slight deposite  of lithates, sp. gr. 1029. 
OR RHEUMATIC FEVER.                H5
Pulse  86.   Heart's action  regular, and sounds  free  from
murmur.
                Repetatur haustus 4ta quaque hora.
                Repetatur Opium hora somni.

   12^.—Slept  at intervals throughout the  night.   The
joints are much easier, and the swelling  has almost  entirely
subsided.  Perspiration continues profuse.   Tongue moister
and cleaner.  Bowels  have acted  once.  Urine  about  2£
pints, clear, light-coloured, faintly acid ; sp. gr. 1030.  Pulse
84.  Heart's sounds natural.
               Repetatur haustus ter in die tantum.

   13^/t.—Did not sleep soundly, but the joints  are  much
easier, and the swelling has entirely disappeared.  Still con-
tinues to perspire profusely, and the skin is becoming sodden.
Tongue  moist  and  almost clean.  Bowels  open.   Urine
about  21  pints,  highly coloured, slightly akaline, sp. gr.
1026.   Pulse 80, soft, and rather  weak.  Heart's sounds
clear.
                 Omittatur haustus salinus.
            Haust. Quinas c. Sulph. Magnesia; 3ss, bis in die.
                 Repetatur Opium hora somni.

   l^th.—Slept  more soundly, and is in every  respect better
to-day.   Pains  much  easier.   Not so  much perspiration.
Tongue moist  and clean.  Bowels rather relaxed.  Urine
abundant,  (about 2 pints,) clear, acid, sp. gr. 1028.  Pulse
76, soft.
         Repetatur haustus Quina? omissa Sulph. Magnesias.

   From this time he went on improving, almost daily, up to
the 22d instant, when there was a slight acceleration of the
pulse, and  a  slight recurrence of coating  of  the  tongue, of
pain in  the right foot, and of swelling in the right hand.
The skin,  however, remained dry; and the urine, though
high coloured, did not become turbid.  I, therefore, did not
deem  it necessary to recur to the former  saline  treatment,
but  contented  myself with ordering him to  take a vapour
bath, to repeat the pills  ordered on the 9th instant, and to
take the following:
               ft.   Liquoris Potassae, flux.
                   Potassii Iodidi, gr. iiij;
                   Mist.  Guaiaei, gjss, ter in die. 
116        TREATMENT OF ACUTE RHEUMATISM
  In  the course of three days  the rheumatic symptoms
had again  subsided, and  he  left the hospital on the 28th
instant.
  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 inflam-
mation.

  In  Case i—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. 1030 in 48 hours.
       ,,     The articular inflammation was greatly relieved
                  within 24 hours, and subsided altogether
                  within 48 hours.
  In Case n—The pulse fell from 114 to 84 in 43 hours,  and
                  to 80 on the third day.
       ,,     The  urine,  from being  scanty  and  loaded,
                  became plentiful and almost clear within
                  48 hours ; and perfectly clear and plentiful,
                  sp. gr. 1032, within three days.
       ,,     The inflammation of the joints was greatly relieved
                  in 4S hours, and subsided altogether on the
                  third day.
  In Casein—The pulse fell from 116 to 80 within 43 horns,
                  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 4S hours.
       ,,     The  inflammation of the joints was almost  sub-
                  dued at the  expiration of 4S  hours, and
                  subsided altogether by the  fourth day. 
OR RHEUMATIC FEVER.
117
   In Case iv—The pulse fell from 120 to 86 in 24 hours, and
                  to 76 in 48 hours.
       ,,      The urine,  from  being scanty  and  loaded,
                  became plentiful  and almost clear, sp. gr.
                  1028, in 24 hours ; and still more abun-
                  dant, sp. gr. 1029, in 48 hours.
       ,,      The articular inflammation was greatly reduced
                  within 24  hours, and subsided altogether
                  in 48 hours.
   In Case v—The pulse fell from 126 to 98 within 48 hours,
                  and to  86 within three days.
       ,,      The  urine,  which at  first was  scanty and
                  loaded, increased  in quantity, and became
                  less  loaded within 48 hours, and very
                  abundant and perfectly clear, sp. gr. 1029,
                  on the fourth day.
              The articular inflammation was  greatly subdued
                  within 48 hours,  and subsided altogether
                  by the end of the fourth day.
   In Case vi—The pulse fell from 116 to 100 within 24 hours,
                  and to 86 within  48 hours.
       ,,      The urine increased in quantity, and  became
                  almost clear  within 48 hours, and  still
                  more abundant and quite clear by the end
                  of the third day.
       ,,      The articular inflammation  was considerably
                  reduced by the end of the third day, and
                  had subsided  altogether by  the end of the
                  fifth  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 disease, and of the means employed to
subdue it.  Indeed,  Cases v and vi were instances of more
than ordinary severity, and Case vi proved unusually obsti-
nate in its continuance.
   On analysing 39 cases which I have treated, after the plan
above detailed, I find that 7 wTere accompanied by symptoms
of endocardial or exocardial inflammation; but that in  2 
118        TREATMENT OF ACUTE RHEUMATISM
only, did such symptoms manifest themselves after the com-
mencement of treatment,  and that  before the full effect of
the  remedies  could be felt.  Excluding these  7 cases,  the
pulse in 23 cases fell between 30 and 40 beats within forty-
eight hours ; in 6 was not subdued  to such an extent until
the  expiration of three days ; in 2 not until the fourth day,
and  in 1 not until the sixth day of treatment.
  There was a great increase in the  quantity of the urine by
the end of twenty-four hours in fifteen cases, by the end of
forty-eight hours in 12 cases, and not until the third day in
5 cases.
  In 3 cases the urine  became  clear within  twenty-four
hours, in 16 within forty-eight hours, in 1 within three days,
in 1  within four  days,  and in 1 on the fifth day.   In 10  the
urine was not saved ; and this point, therefore, 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
on the second day, in 1 instance ;  on the third day, in 4 in-
stances ; on the fourth day, in 3 instances; and subsequently
to that period, in 1 instance.   In  13 instances it never alto-
gether lost its acidity,  and in 10 the fact could not be  ascer-
tained.
  The articular inflammation was greatly relieved within
twenty-four hours in 11  cases, within forty-eight hours in
17 other cases, within three days in 2 cases, and within four
days in 1 case.
  It subsided altogether within twenty-four  hours in 1 in-
stance, within forty-eight hours in 7 instances, within three
days in 8 instances, within four days in 7 instances, within
five days in 3 instances, within seven  days in 2 instances; and
in the remaining 4, although it did not wholly subside until
a later period, yet it did not  display any symptoms of activ-
ity after the fourth day.
  In four instances only did the medicine produce any dis-
agreeable effect.  In all these it gave rise, in the first instance,
to nausea, and in 1 to occasional vomiting.  In 3 of these 4
cases the nausea subsided after the first few doses; in  the
other, which was one of the two in which the articular inflam-
mation was not wholly subdued until the end of the seventh
day, the salines had to be  omitted, not only  on account of
the continued nausea, but because of their purgative action.
Indeed, in all these four instances, and in two others in which 
OR RHEUMATIC FEVER.
119
nausea was not produced, the  salines had  to  be omitted
before  the articular inflammation was wholly subdued,  in
consequence of the impossibility of restraining their purga-
tive action by any moderate quantity of opium.  These were
invariably  the cases in which the  remedial power of the
salines was least  strikingly  displayed;  and I cannot help
thinking that the want of success depended, as in many of
the cases treated  by lemon  juice, upon the absence of a
sufficiently active  converting power in the stomach.  The
salt was not assimilated,  and therefore  did  not act as an
alkali, but accumulated in the system and operated as a pur-
gative.   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
depurant.
   The only uncertainty attaching to any of the above-stated
results, is that arising from the difficulty in arriving at a cor-
rect 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 labouring under acute rheumatism. In every instance,
however, great care was taken to obtain as close an approx-
imation to the truth as possible.
   In  fifteen cases, not only was  the  quantity of urine  in-
creased,  but its solid constituents, as shown by its increased
specific gravity, were also greatly augmented.  In six of the
other seven cases, although  the urine increased in quantity,
there was only a slight corresponding increase in its specific
gravity,  and in one the specific gravity was  slightly dimin-
ished.   This variation in the quantity of the solid matters ex-
creted by the kidneys, was attributable, I  believe, not  to
any difference in the  quantity of the morbific matter pres-
ent in the system, but to the varying activity of the cuta-
neous  and intestinal secretions, whereby it  happened that
in certain cases a far larger amount of matter was carried off
by those channels than could possibly 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 and 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 internal complications having been unsought for and
 undiscovered.  But clinical observation and pathological re-
 search have now unfolded  changes in the internal organs of
 the deepest import;  they have discovered the important and
 fearful fact that, accompanjdng  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,—inflammation of an  organ,  the mechanism of
 which is most easily deranged, and which, when deranged,
 " lays its own hard conditions  upon the continuance of a
 man's life, and almost settles beforehand the manner of his
 death."1
  Inflammation of the heart is now recognised 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  he  apparently recover and  resume his wonted avoca-
 tions? he is taught, alas !  at no distant period, that there is
 yet in store for him a frightful amount of suffering, a long-
 continuance of asthma, palpitation, and dropsy, as the result
 of his former cardiac affection.
  Such being the dangers,  and  such the suffering attached
 to rheumatic cardiac affection, it behoves us to  investigate
the cause of its occurrence, the class of cases in  wdiich it is
most liable to arise,  and the possibility of guarding against
its invasion.
1 Dr. Latham's 'Clinical Medicine.' p. 156. 
RHEUMATK! AFFECTION OF THE HEART.        121
   The  first  question which arises is as to  the cause of its
occurrence.   On what  does rheumatic inflammation of the
heart depend V
   It was formerly supposed to be  due to metastasis, or, in
other words, to the  retrocession of the disease from the ex-
ternal parts, and its consequent transfer to  the membranes
of the heart.   But more recent and  more extended observa-
tion has shown that endocardial or exocardial inflammation
may  occur as the first, and, for some time, the only local
symptom of the disease ;2 that it sometimes precedes, by several
days, the access of articular redness and swelling,  and that
even in cases where it does not take place until after inflam-
mation of the joints has been set up, it is rarely preceded or
accompanied by subsidence of the previously existing articu-
lar 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 inflamma-
tion, 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 another, re-
versing the  order  of its attack, and exciting  inflammation,
first of the heart and then of the articular structures.  Hence,
although rheumatic inflammation of the heart may possibly
be connected, in some rare instances, with the sudden subsi-
dence of articular inflammation, and the transfer of irritation
from the external  parts, it must be regarded, in most in-
stances, as a mere coincidence, and  as  an extension of the
local manifestations of the disease.
  1 Throughout this Chapter, I make use of the expressions " inflammation
of the heart" and " cardiac inflammation," as applying indifferently to in-
flammation of the endocardial or exocardial membranes.
  2 Three instances of this sort have fallen under my own observation.  In
two cases, the patient laboured under pericarditis two days, and in the other
three  days, prior to the appearance of articular inflammation.  My col-
league, 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 favoured me with the particulars of
another ; one is quoted in Dr. Graves's ' Clinical Medicine,' ed. 2. vol. ii, p.
100 ; 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, by  Dr. Duncan,
in the 'Edinburgh Med. and Surgical Journal' for 1816; one, by M.  Hache,
in the 'Archives Generales de Medecine,' vol. ix, p  325 ; and two others,
by Dr. Taylor, of Hnddersfield,  ' Medico-Chir.  Trans.,' vol. xxviii, p. 527.
Others also are to be found recorded in various medical periodicals. 
122
ON THE CAUSES OF
  I have thought it right to be thus explicit in stating my
conviction 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 imme-
diate and practical bearing on the questions at issue, namely,
the class of cases in which cardiac inflammation is most lia-
ble to arise, and the possibility of guarding against its occur-
rence.   If, as I believe, 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  ob-
tained  by a close  observation of the  circumstances which
influence  the  articular  inflammation.   If, like the external
redness and swelling, this internal inflammation be due to
the  irritation of a  materies morbi  present in the blood,
and circulating with it to every part of the body, then may
we 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 modify-
ing power.
  What, then, are the  facts with regard  to  the articular
inflammation ?
  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 influ-
ence.  It does not attack all the joints indiscriminately, but
selects different joints  in  different cases;  those which are
most used, or which have  been the seat of injury or  irrita-
tion, being more than ordinarily liable to  its invasion. It
attacks a large number 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 pre-
vented  and subdued, by the use of alkaline and opiate
fomentations, and by the exhibition of medicines which serve
to counteract  the rheumatic poison, to promote its elimina-
tion, and to prevent its further formation.1   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
1 For illustrations of this fact, see Cap. V, of this Treatise. 
          RHEUMATIC AFFECTION OF THE HEART.        123

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 constitutional pe-
culiarity, or from  extraneous and temporary causes, its irri-
tability is unusually exalted; and that it should be protected
by the exhibition of such medicines  as are calculated to ex-
ercise a sedative influence over it, to counteract or destroy
the irritant property of  the  rheumatic element, and to pro-
mote its elimination from the system.
   Some difference of opinion has been expressed as to the
existence 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
" Pericarditis  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 ac-
companiment  of severe  articular rheumatism, and occurs not
unfrequently  when the articular symptoms are  slight, or
altogether  absent, I entirely 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 inflammation may have been slight or
evanescent, the febrile  disturbance has  always been severe,
and accompanied by profuse and sour-smelling perspiration.
As many as 114 out of the 130 cases of recent heart affec-
tion 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 two 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 1 in
every 66-5 cases of the  subacute form.  Nor is the result of
my  experience inconsistent with that  of other observers.
Amongst 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 endo-
carditis was certain, and 3 in which it was doubtful, whilst 
124
ON THE CAUSES OF
among the 40 of the second class its existence was only once
discovered.1  Dr. Macleod, without giving any statistics on
the subject,  says, very decidedly, " according to my expe-
rience the heart affection is more frequent in severe than in
mild  cases of rheumatism."2  Dr. Copland  is of the same
opinion ;3 and  Dr. Wm. Budd believes " that rheumatic in-
flammation of the  heart is most common  in severe  cases,
especially when there is much fever, and the parts affected
are numerous.4
  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 some-
times suffer, even in the milder cases, it  is most commonly
damaged in  those  instances wdiich are marked by  unusual
severity of their general symptoms, by the number  and in-
tensity  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  orsran is  most
imminent"?
  Experience  and  observation  have  long  since  supplied
abundant data for a  solution  of this problem.  It is  noto-
rious that,  in youth,  the heart's action is not only quicker
than in  more advanced life, but that it 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,5 and in those  peculiar states of system
which are  marked by a deficiency of red globules in the
blood, the heart's irritability is much increased, and palpita-
tion is  readily  induced.   These, then, are  the  cases, theo-
  1 ' Traite Clinique du Rheumatisme,' Preface, p. 12.
  3 On ' Rheumatism,' p. 45.
  3 ' Medical Dictionary,'  vol. ii, p. 195.
  4 ' Library of Medicine,' vol. v, p. 199.
  8 The experiments of Messrs. Andral and Gavaret, recorded in the
' Annales de Chimie,' vol. lxxv, 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, 
          RHEUMATIC AFFECTION OF THE HEART.        125

retically at least, in wdiich 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 rheum-
atism, when occurring in youth, than when occurring in those
more advanced in years.1  Statistical observations have shown
that it is more common in women than in men ;2 and I have
always been  struck,  both in  private  practice and in the
wards of St.  George's Hospital, 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, cceteris 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
previous 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 irrita-
bility 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 wdiich tends to augment
the heart's irritability, must  tend, pro tanto, to render the
patient liable to heart affection ; whilst anything having  an
opposite tendency must serve, in some measure, to shield him
from  such a  complication.   Hence, although  a  moderate
venisection  may sometimes be  necessary for the relief of
in which the heart is peculiarly irritable. Three of these experiments give
the following results:
Amount of glo- } Case i. bules in 1000 > „ ii. parts of blood. ) „ iii.	1st Bleeding.	2d Bleeding.	3d Bleeding. 4th Bleeding.	
	114-8 125-3 123-7	111-0 124-9 120-7	102-8 121-4 112-8	8S-7 99-6 101-0
  Messrs. Beequerel and Rodier also sum up the result of their experi-
ments by stating " the effect of vensesection is to cause a great diminution
of the corpuscles, while it only slightly lessens the  amount of albumen."
(Simon's ' Chemistry,' vol. i, p. 250.)
  1 Dr.  Watson, Dr. Macleod, Dr. Todd, and others, hear witness to this
important and significant fact.
  a See  Cap. IN, of this Treatise. 
126
ON THE CAUSES 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 correct-
 ing the morbid condition of the  blood and promoting the
 elimination of the materies morbi, directly tend  to obviate
 inflammation by removing its cause, whilst with opium, col-
 chicum, and other medicines, they exert a sedative influence
 over the heart, and thus tend, in some measure, to protect it
 from danger.
   In thus enunciating my  views on the subject under con-
 sideration,  I have  purposely  avoided discussing the  oft-
 mooted question,  as to whether a proneness to inflammation
 of the heart may, or  may  not, be induced by  venaesection.
 A discussion of this sort can hardly 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 ques-
 tionable grounds.   I have,  therefore, contented myself with
 pointing out  those  facts which have appeared to me most
 interesting  and suggestive ; and it need only be stated, that
•by applying the inferences from these facts to practice, re-
 sults have  been obtained far  exceeding in importance  my
 most sanguine expectations.   Not only has the  pain been
 subdued, and the course of the  articular inflammation arrest-
 ed with unusual certainty and rapidity, but in almost every
 instance the accession  of inflammation of the heart has been
 entirely prevented.
   The  treatment  which  has proved most efficient  for this
 purpose, is that which is directed against the  pathological
 condition of the system, out of which arises the tendency to
 inflammation, 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  possi-
 bility of affording protection to the heart by a  strict avoid-
 ance 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 39 patients
 whom I have treated for rheumatic fever since I  first adopted
 this plan of treatment, inflammation, whether  of the peri-
 cardium or endocardium, has occurred in only seven instances, 
          RHEUMATIC AFFECTION OF THE HEART.        127

and in five of these the heart was affected before the patient
came unde? my care.1
  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  subsisting between  rheumatism and the forma-
tion of fibrinous vegetations on the valves and on the lining
membrane of the heart.  By common consent this cardiac
affection has been ascribed to endocardial inflammation, and
its presence has been cited as conclusive evidence of the ex-
istence of endocarditis  at some former period.  Observation,
however, has  led me to take a different view of the matter,
and to consider that these fibrinous deposits, though common
accompaniments of  rheumatic  endocarditis, are, neverthe-
less,  essentially  independent of endocardial inflammation,
and may, and do take place,  without its occurrence.
   The  grounds  on  which  this  opinion  is  based,  may be
briefly stated.  Foremost among them is the frequent occur-
rence of valvular murmurs,  dependent on organic mischief,
in cases which do not present any symptoms of true cardiac
inflammation.  Thus, frequently during  the  active  stage of
rheumatism, and sometimes  during recovery from  the dis-
ease, whilst the  tongue is  cleaning, and the various  symp-
toms 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 to accompany endocarditis ;2 that it
is caused by organic mischief, is often rendered probable by
  1 In one of the other two cases an exocardial  murmur,  which was
not  discovered when the patient first came under my care, was distinctly
heard  on the second day, and may possibly have existed  in an incipient
state, though it escaped detection on the first day; in the other, the case
of Ford. Chap. X, an endocardial murmur  manifested itself on the third
day of the treatment.  In that case, however, I had only seen  the patient
once before the commencement of the cardiac mischief.
  2 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
which  arise in the course of acute rheumatism would, if always  referable to
inflammation, lead us to suppose. 
123
ON THE CAUSES OF
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 results of post-mortem examinations.  In-
deed 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.1
On the other hand, it is certain that, in some instances, at
least, no unusual  effects result  from endocarditis, for I have
seen three examples of that disease, marked during life by
all  the ordinary local  and  general symptoms of inflamma-
tion, and exhibiting, after death, unmistakeable evidences of
inflammatory action, such as minute capillary injection, with
a swollen condition of the valves and effusion 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. Orme-
rod has also recently quoted a case, related by Dr. Kirkes, of
true rheumatic endocarditis, in which the valves were dis-
tinctly swollen and vascular, and yet were unincumbered by
fibrinous growths.2   He has also favored me with the partic-
ulars of another, in which a similar condition was observed.
As then, at one time, recent fibrinous vegetations are  found
in great luxuriance  on valves which  present no trace  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 val-
vular inflammation and  fibrinous accretions, though  often
coexistent  phenomena,  are  yet  essentially  independent of
one  another.    Indeed,  experiment has  shown,   that fibri-
nous vegetations are not necessarily connected with inflam-
mation at the  spot where their formation is observed; and
thus, again, we are  forced to revert to deposition from the
blood in explanation of the phenomena in  question.  Nor
does such an  explanation appear  improbable, when we con-

  1 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 th« commencement of a systolic aortic murmur.
  8 Gulstonian Lectures, for 1851, p. 29. 
           RHEUMATIC  AFFECTION OF THE HEART.        129


sider the  close relationship of  the endocardium and the
blood;  for what can be  more reasonable  than to suppose,
that some change may be effected in the blood in immediate
contact with the irritated membrane,  and that fibrin may
sometimes be deposited in consequence?   If under  any cir-
cumstances the deposition of fibrin be possible, wliat can be
more likely than  that such a deposit should take place in
acute rheumatism when the  blood is surcharged with the
material in question, and when, from  the extreme acidity of
the  system, it is in a state  by no means well  calculated to
hold it in solution ?
   That these fibrinous deposits are connected with some ab-
normal 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, but probably impair its solubility.1   And since it has

   1 During the  time I held the  office of Medical Registrar  at  St. George's
Hospital, I observed, th:it although every other form of valvular disease oc-
curred not unfrequently without any previous or concurrent inflammation,
yet, that no deposit of fibrin was ever found, except where there cither 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 since been  published by my
friend, Dr. Barclay, the present medical registrar of the hospital, (' Medico-
Chir. Trans.,' vol. xxxi,) a further confirmation of  my views may be de-
duced, for in every instance in which fibrinous deposits were found on the
valves, there either existed or had previously existed some such mischief.
This will be seen on reference to  the subjoined facts. Out of 75 cases of
valvular disease examined at St.  George's Hospital, 21 were instances of
fibrinous deposits. The history of these 21 cases is as follows :
  ]. ( Old Rheumatic Fever. Recent Pleurisy, and adhesions resulting from
                           a former attack of Pleurisy.
 2.   Recent Rheumatic Fever.  Recent Pericarditis, Pleurisy, and Pneu-
                               monia.
 3.   Old Rheumatic Fever.  Recent Pericarditis.
 4.           "        "    Pneumonia.
 5.           "       "    Recent Pericarditis, and adhesions resulting
    J                       from a former attack of Pericarditis.
              "       "    Recent Pericarditis, Pleurisy, and  Pneumo-
                            nia.
              "        "    Recent Pericarditis, and Pleurisy.
              u        "    Old adhesions resulting from former attacks
                           of Pleurisy and Pericarditis.
              "        l;    Pneumonia,  and  adhesions  resulting from
                           former Pleurisy and Pericarditis. 
130
ON THE CAUSES OF
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 where irritation has been excited,1 we cannot be sur-
prised that  they should 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 inter-
pretation 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  sometimes are, to the angular projec-
tions 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 character-
ized, as  the  blood  in  acute rheumatism 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
10. f Rheumatic Fever, doubtful.  Pneumonia and Inflammation of the
   j          ;;         "       Brain.
11. <          *'         "     Pneumonia and recent Pericarditis.
12.           "         "     Adhesions,  the result of a former
                               attack of Pleurisy.
13. f No mention of Rheumatic Fever.  Adhesions, the result of a former
                                   attack  of Pleurisy.  Diseased
   I                               Kidneys.
14. ■{          "         '•         Recent Periearditis, Pleurisy, and
                                   Pneumonia, and adhesions, ihc
                                   result  of former  Pericarditis.
                                   Mottled Kidneys.
                        Pneumonia.
                        Recent Pleuiisy,  with excessive congestion of
                          the Lungs, and  adhesions,  the result of
                          foimer Pleuiisy.  Diseased Kidneys.
                        Recent Pericarditis.  Diseased Kidneys.
                        Pneumonia,  and adhesions  resulting fiom
   <(                      former attacks of Pleuiisy and Pericarditis.
                          Diseased Kidneys.
19.         "        "    Recent Pleurisy, and  adhesions resulting fiom
                          a former attack of  Pleurisy.
20.         "        "    Recent Pericarditis.
21.         "        "    Adhesions resulting from a former attack of
    L                      Pleurisy.
  ] See the account of Dr. Hope's experiments on the ass.
		
15.	' No Rheum	Aic Ftver
16.	.(	.<
	d	k
17.	«	i:
18.	d	i.
 
          RHEUMATIC AFFECTION OF THE HEART.        131

probable; and even if there be no endocardial inflammation,
the formation of such a deposit on the strained and excited
valvular apparatus can hardly be regarded as improbable.1
  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 va-
rious forms of rheumatic heart affection.  Thus, in  rheuma-
tism complicated 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.2  The pulmonary inflammation is certainly due
to the same cause  of  irritation  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 val-
vular murmurs be in all cases referable to endocardial inflam-
mation, the  difference  in  the  frequency with which peri-
carditis and endocarditis are respectively accompanied  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
occasions occasioned  by the deposition of fibrin occurring
independently of active endocardial inflammation, the appa-
rent inconsistency is at once explained.  And it is rendered
probable that the variation observed in the proportion which
pulmonary inflammation  bears to the different  classes of
heart affections,  may serve to indicate, with tolerable accu-
racy, the frequency with which valvular  mischief arising in
the course of rheumatism is not referable to true endocardial
inflammation.
   By some persons the frequent coincidence of pericarditis
and inflammation of the lungs  or their investing membrane
  1 My friend Dr. Ormcrod 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 attract fibrin from the passing
b'ood, even in a healthy individual, such an  event might yet more readily
ensue in a case where the blood has already a strong tendency lo deposit
fibrin. Such is the case in acute rheumatism, as appears not only from the
anal) sis of the blood, but from the large inflammatory exudation into the
pericardium  or pleura,  whi. h  occurs  coincidently in some such cases."
(Gulstonian Lectures, for 1851, p. 30.)
  2 For full particulars on this subject, see Chap. X, of the Treatise, 
132
ON THE CAUSES OF
has been referred to the close proximity of the inflamed parts,
inflammatory action having a  tendency to spread  by con-
tiguity 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 membrane 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 coin-
cidently with  or during the progress of  pericarditis, it is
usually caused by the same agency which induced the orig-
inal attack of inflammation.1
  It has been argued that if these fibrinous  growths were
indeed the products of simple deposition on the lining mem-
brane  of the valves, they would be easily separable from the
subjacent tissues.   That in most recent cases they arc readily
separable from the subjacent tissues must be admitted, and I
can assert, from repeated personal observation, than  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
  1 The following statistical record of 265 cases of recent pneumonia, pleu-
risy, or pleuro-pneumonia, which occurred in St. Bartholomew's Hospital,
and with which I have been favoured by my friend Dr. Ormerod. of Brighton,
confirms the result of my experience at St. George's.  The 2G5 cases 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 pleuro-pneumonia  "      8 or 1  in  77       "

Thus of 265 \ cafS °f reCent pulmo,10ry \ 33 or 1  in 8 . *ere implicated
          $ inflammation  -    -    - $        "" \  by 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 mate-
rially inti rfere 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 iu the table were doubtless referable to the same
cause which produced the pulmonary affection, and were in no degree attrib-
utable to the spread of inflammation, in consequence  of the contiguity of the
parts. 
          RHEUMATIC AFFECTION OF THE HEART.       133

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 mischief.
  But the structures which constitute the valvular apparatus
are sometimes firmly matted together, and such a condition
undoubtedly  points to  some antecedent thickening process,
probably of an inflammatory nature.  Its existence, therefore,
in the majority of these cases, is very important and suggest-
ive.   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 phe-
nomena; 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 depo-
sition of fibrin, yet that not unfrequently it takes place sub-
sequently 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 appearance 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, that if we would
preserve the heart from mischief, it is necessary not  only to
take precautions  against inflammation, but to maintain, at
all hazards, the solubility of the fibrin.   For both these pur-
poses, 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 
134
ON THE CAUSES OF
in the quantity of fibrin ;J and by increasing as they do the
solubility of that material, 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 body,
and  fixing more particularly  upon those which are in  any
way subjected to irritation.2  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,
caterisparibus,  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 accu-
rate 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 affec-
tions, not only as indicating the presence of a large amount
of morbific matter, and a peculiar susceptibility of its irrita-
tion, 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 liability to cardiac
inflammation,  engendered  by the repression or rapid subsi-
dence of  the  articular inflammation, is  explicable by the
greater quantity of the poison which is thus  suddenly thrown
into the blood's current.
  1 The experiments of Messrs. x\ndral 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 soo 1 after the leal inflammations
have been subdued.
  a "In  the heart, as in the large articular structures', the  fibre 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 continual attrition in the pericardium, and in the cardiac
valves maintains its office by strain, and with a pull.  Oi the other hand,
the dura mater and periosteum, 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,*
1 Lancet' for 1844, vol. ii, p. 217.) 
          RHEUMATIC AFFECTION OF THE HEART.       135

  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: it is
essentially independent of valvular inflammation, and may
or may not occur coincidently with it: the probability of its
occurrence, however, is  greatly increased  by the existence
of active  valvular inflammation, inasmuch as the slightest
roughness or unevenness on a valve, such as would be likely
to arise from  inflammation, would form  a nucleus for the
deposit of fibrin, and would thereby favour the tendency to
its deposition.  Moreover, its occurrence must be rendered
probable, by  the existence of  active  articular inflamma-
tion, on account, not only of the vast augmentation in the
quantity of fibrin which is thereby  effected, but of the ex-
treme  acidity of the system  which  such a  condition im-
plies,  and  of the  weak state  of solution  in which the
fibrin must consequently be held.  It takes  place  on the
valves  in  preference to other  parts  of the heart, partly
in consequence  of the extreme  susceptibility to the irrita-
tion of the rheumatic poison exhibited by the fibrous tissue
which enters into their composition;  partly in consequence
of the  excited state in  which they are kept by their un-
usually 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; and partly, also, in consequence of the strong ten-
dency which  exists to the deposition  of fibrin on anything
projecting into  the arterial current.  A further considera-
tion of the  circumstances,  under which these accretions
take place, serves also  to  explain  why the angular pro-
jections and the  edges of contact of the valves are frequently
loaded with fibrinous  deposits,  whilst the surface  and free
edges   of  the valves, and  other  parts  of the  endocardial
membrane, retain their healthy,  unencumbered condition.
For nothing can be  more certain, than that fibrinous depo-
sition may be determined to a spot by any cause calculated
to roughen or  irritate  the endocardial  membrane;  and
the  angular projections and  the  edges  of contact  of the
valves are just the parts which are most subjected to ten-
sion, attrition, and pressure. 
CHAPTER  VII.
       ON RHEUMATIC INFLAMMATION OF THE HEART.

  In the preceding Chapter  I have endeavoured 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 afterwards to proceed to
the exposition of its physical signs and general symptoms.
By  following this course, the latter* will be more readily un-
derstood and appreciated, as they will thus be recognized as
the natural results of the local changes induced in the  heart
and its membranes, 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 inflamma-
tory action, its investing and lining membranes, the pericar-
dium and the endocardium, are both apt to be implicated in
the mischief which takes place.  Pericarditis, however, is oc-
casionally 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 peri-
cardium.  Under these  different circumstances lesions are
produced, which differ widely in their  seat  and character,
and I 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, how-
ever, to a full understanding of the subject, to take into con-
sideration 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 both these products in varying proportions :  or sometimes, 
ITS PATHOLOGICAL EFFECTS.
137
more especially in unhealthy subjects1, by a serous effusion
more  or  less tinged with blood, and mixed with curdy, ill-
concocted lymph, having  a tendency to assume a puriform
character.  But the pericardium is not only a serous mem-
brane, it  is also a  shut sac, the two opposed surfaces of which
are in contact 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 inflamma-
tion may sometimes be 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 membrane.
   The effects which follow an attack of pericarditis vary ac-
cording to the extent of the disease and the character of its
products 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 gradu-
ally reabsorbed 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 sur-
faces 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  adhe-
sions 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 universal adhesion may
take  place as before; whilst, if it  consist chiefly of serum
mixed with pus, or with shreds of curdy lymph  of low vital-
ity, or if the serum  be very copious, and be  not readily ab-
sorbed, adhesion  sometimes fails to take  place, the sac of the
  11 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. 
138     RHEUMATIC INFLAMMATION OF THE HEART,

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 ex-
perience, such is generally the case when adhesion occurs be-
tween those parts of the pericardium wdiich are naturally in
apposition;  and even when parts not naturally in apposition
have become adherent, a temporary and partial recovery may
ensue, and the sufferer, 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 seve-
ral 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 suffoca-
tion, until, after the lapse of a short  time, sometimes  in the
course of a few days, his life and his sufferings  are terminated
rather suddenly by death.
  It has been suggested  that the lymph effused in pericar-
ditis 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.  Doubt-
less it may be reabsorbed to a very great  extent, so  that a
thin layer  only may remain where a copious and thick de-
posit 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
favourable issue we are justified in expecting, when  pericar-
ditis has been extensively diffused over the membrane.  For
although we see and know that the lymph  poured out in
iritis disappears, and are  bound to  admit that there is no
a priori  impossibility in  the  reabsorption  of  the  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
comparatively small, its absorption  may  be  effected  under
the influence of mercury before it has time to  become organ-
ized.  But in pericarditis the constant attrition  of the  two
inflamed surfaces  keeps up and  aggravates the existing  in-
flammation, so that it  endures for a lengthened period ; the 
ITS PATHOLOGICAL EFFECTS.
139
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 apposition, it  is difficult to conceive how
they can fail to become adherent.   But our  post-mortem
records  show clearly and  indisputably that  a small  and
partial effusion of lymph may  sometimes  accompany  peri-
carditis,  and that not unfrequently lymph is  curdy  and
but  slightly  plastic.   In both  these  cases the  adhesions
may fail  to take place.  In the first, because the lymph,
even if plastic, is not in quantity sufficient 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 accom-
panied by a copious effusion of  serum, which keeps the two
surfaces of the pericardium asunder, until by continued wash-
ing  it  is  rendered shreddy,  and, for the most part, inapt for
the purpose of adhesion.  In such cases, doubtless, absorp-
tion of the lymph is gradually effected 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 xxm of the  ' Medico-Chirurgical Transactions.'
But in ordinary 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 absorption as next to impossible.
   Thus, then, to speak in general terms, the primary effects
produced by extensive inflammation of the investing mem-
brane  of the  heart  are, first,  effusion,  either of lymph or
serum, or of serum  mixed with coagulable  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, 
140     RHEUMATIC INFLAMMATION OF THE HEART,

indeed, does it take place at a very early date, but it some-
times happens before,  sometimes not until  after, adhesion
has taken place.   Thus the morbid appearances  observed
on dissection vary both with the character of the inflamma-
tion  and with the  period at which the attack  has proved
fatal.  If death has occurred early,  traces of inflammation
may often be 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 condi-
tion  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 surface of  the membrane will be seen diighly
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 will be found, but a
large amount of plastic lymph, often tinged or mottled with
blood, will be  seen deposited in successive layers on the in-
ternal 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 ap-
pearance varies according  to the amount of 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  organiza-
ble,  and serum be present in sufficient quantity to keep the
two  sides of the sac asunder, and thus prevent their imme-
diate adhesion, 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 adhesion great, very slight lateral motion
of the membrane can  take place, and a spongy, or honey-
comb, or  tripe-like appearance, is produced by the repeated
contact and separation of the two inflamed surfaces.
   These are the appearances observed when the patient falls 
ITS PATHOLOGICAL EFFECTS.
141
an early victim to the attack ; but when he dies, as he some-
times does, at  a later stage of the complaint, soon after  the
pericardium has become  adherent to the heart, there  are
other points worthy of observation.   The  medium of adhe-
sion 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 recur-
rence of  pericardial inflammation.  But in this  lymph may
be seen here and there some bloody spots or streaks, or anas-
tomosing red  lines, the  first indications of its commencing
organization.
  And if a still longer period elapses before death, the or-
ganization 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 network
of fine adhesions having  a smooth  glistening surface,  and
presenting the characters of serous membrane.
  Such are the effects, such the changes produced by inflam
mation of the investing membrane of the heart,  and inflam-
mation of  its internal or lining membrane gives  rise to
lesions equally striking and disastrous.  The natural trans-
parency  of the membrane  may be  replaced by whiteness
and opacity, fibrin may be deposited upon it, forming beaded
or wart-like fleshy excrescences, and lymph may be effused
either beneath or on its  surface, giving rise to  thickening,
rigidity, and puckering.   In some cases I have known ulcer-
ation ensue, which has not only produced a perforated con-
dition 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 thus been eaten through and rendered
useless.   Some cases too are on  record, though I have never
met with such, in which  suppuration of the muscular sub-
stance of the  heart has taken place, and has caused perfora-
tion  of  the  septum ventriculorum.1   Happily, however,
phenomena such as these are seldom the result of rheumatic
inflammation; and when they  do occur, they  may be re-
garded as the offspring of a peculiarly unhealthy constitu-
tion.
  It  sometimes happens that  inflammatory products  are
  1 For cases in illustration of this fact, see Dr. Watson's ' Practice of
Physic,' ed. 1, vol. ii, p. 287, and a report by Mr. Avery, in the 2d volume
of the ' Trans, of the Pathological Society of London.' 
 142     RHEUMATIC INFLAMMATION OF THE HEART,

 found in the different chambers of the heart, more especially
 in the left auricle; but in most instances they are confined
 to the valvular  apparatus or its immediate neighborhood,
 and the  mitral and aortic valves appear peculiarly liable  to
 suffer.   The right cavities, however,  with  their tricuspid
 and pulmonary  semilunar valves,  are  sometimes,  though
 rarely, affected.1
   The fibrinous vegetations, which  constitute the most fre-
 quent form of rheumatic valvular  lesions, vary greatly  in
 their appearance in different  cases and at different 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  distinct from each other,  at
 another partially confluent;  and when several spring from a
 common base, they may form a mass  of 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 constitution,
 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 tumours, which
 hang loosely into the ventricle, and are moved to and fro by
 the current of the blood.2  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 sig-
moid valves they are arranged in a double crescentic form ;3
 but when their growth is more luxuriant, as in the instances
 last alluded to, they are  more widely distributed over the
 endocardial membrane.  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 tin abundant
 crop of them ;  and' occasionally in the different chambers  of
the heart, more especially in the left auricle, they are  scat-
  1 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.
  2 Some of these masses, measuring from half an inch to an inch in length,
are preserved in the Museum of St. George's Hospital.
  8 Dr. Watson's ' Lectures.' ed. 1, vol. ii, p. 267. 
ITS PATHOLOGICAL EFFECTS.
143
tered profusely over the entire surface of the lining mem-
brane. 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 mani-
fest  a strong tendency to  decay,  and in which arise those
formidable  erosions and ulcerations, already mentioned as
sometimes accompanying rheumatic endocarditis.1
   The microscopic examination of these fibrinous deposits
establishes the identity in nature of their different forms, and
shows that they are sometimes granular, but more  generally
imperfectly fibrous  in texture,  presenting  somewhat of a
laminated appearance; and that throughout their structure
are numerous granules and granular masses, and oil globules
in varying proportions.  In some instances of old standing
rheumatic endocarditis,  I  have seen cartilaginous and  cal-
careous deposits on the valves and in the fibrinous  deposits;
but this, doubtless, has resulted from earthy or atheromatous
degeneration, which has taken  place  subsequently to  the
attack, in which the valves were injured or the fibrin first
deposited.
   In colour and consistency these accretions vary just as
much as  in size and in position.   They are sometimes grey
and friable, sometimes of a pink or reddish colour, soft,  and
easily broken down, and can readily be  detached  from the
smooth surface of the membrane  on which  they are depos-
ited  ; at others, they are less coloured,  and of a much firmer
consistence, but still admit of being separated from the mem-
brane ; whilst, in another class of cases, or rather at a more
advanced  period of the disease, they become perfectly colour-
less, and so firmly adherent, that they can be removed only
by tearing the membrane 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 endocar-
dial membrane, and incorporated with the structure of the
valve; and  merging  gradually into one  another,  until  the
  1 " 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
perforations, 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. 253 ) 
144    RHEUMATIC INFLAMMATION OF THE HEART,

divisions between the several granules are effaced, they are
ultimately replaced by a laminated 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  ten-
dency to the repair of these valvular lesions ; but when,  as
is frequently the case, there exists a tendency to further dis-
organization, the  changes which occur  are  of a  different
character.   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  degeneration takes place, and the
valvular apparatus,  strained by the  unwonted force  and
frequency  of  the  heart's action, and rendered  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, result-
ing 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 ultimately 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 peri-
cardium.  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  network of adhesions.  The slightest adhesions must
certainly embarrass the heart's action to a greater or less
extent; yet wdien  they are partial only, and  take place be-
tween such parts  of the pericardium 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 ex-
pected.   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 
ITS SYMPTOMS AND PROGRESS.
145
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 j1 palpitation
and dyspnoea  ensue,  and  the organ, struggling  to overcome
the resistance, becomes gradually more and more dilated and
hypertrophied, until, when it is unable any longer to  fulfil
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 con-
nected with  an impeded pulmonary circulation :—a loading
of  the  capillaries with  dark-coloured imperfectly aerated
blood, coldness and  lividity  of the extremities, blueness of
the lips and face, congestion 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 proportionate amount  of suffer-
ing.  Excessive palpitation, with  praecordial pain and an-
guish ;—paroxysms  of dyspnoea threatening suffocation, or-
thopnoea, constant restlessness, and impossibility of sleep ;—
these are among the inevitable consequences of such an
embarrassed  state of the  vascular and  respiratory system,
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, inas-
 much 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 re-
 sult, 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 excep-
 tion being in the case of patients who, from their position in
 life, have been forced  to pursue some laborious occupation.2

   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
 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 position, the heart at each  systole dragged upon the  band which held
 it back, and thereby caused excessive pain and smarting.
   2 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
                      10 
 145     RHEUMATIC INFLAMMATION OF THE HEART,

   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 lengthed period has  elapsed.  In this
 case 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 main-
 tenance of the circulation.   If the  valves be not actually
 broken down by ulceration, or loaded with fringes of fibrin-
 ous deposits, they wdll probably be rendered thicker and more
 right than natural, or will bear on  their angles  small bead-
 like or granular accretions.  In order to overcome the obsta-
 cle thus presented to the circulation, the heart will have to
 contract more forcibly than natural.  Thus, if the obstruc-
 tion be  permanent, and  the increased labour of the heart
 continue, hypertrophy of its walls and dilatation of its cavi-
 ties 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 pa-
tient, and other collateral circumstances, but ceteris paribus,
it will bear a tolerably constant relation to the amount  and
nature of the valvular disease.  The more serious the mis-
chief, 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 effect the
action of the heart, and  there is, I think,  presumptive  evi-
dence  to show that some thickening of, or deposit  on the
general adhesion of the pericardium.  He is now twenty-five years of age
and has never yet experienced the slightest heart symptoms.  As a boy, 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 un-
easiness ; but from the age of eighteen he has lived a quiet life, and I can-
not perceive any alteration in the condition of the heart since that time. Nor
do I believe this to be a singular instance.  Dr.  Wm. Budd, who has  had
great experience in these matters, reports that he has " seen a great num-
ber 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 dur-
ing life (almost ?) perfectly performed."  (' Library of Medicine,' vol. v, p. 
ITS SYMPTOMS AND PROGRESS.
147
valves may take place, and may be 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 (Edematous 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 reabsorbed, 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 some-
times happens,  the  valves are coated with plastic  lymph,
and  become more or less agglutinated  together, or one of
them, perhaps, folded on itself, and its apex glued either to
the adjoining surface 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 impossible;  but presumption  favours  the belief,
that  in  ordinary cases it is  often effected more  or  less
perfectly.  The   absorption of the lymph effused in peri-
carditis affords a proof that  the processes 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 : dissection has shown that  the process of reparation
does some times advance to a considerable extent:1  and observ-
ation has proved, that functional if not organic  repair may,
1 Antea, p. 144. 
148    RHEUMATIC INFLAMMATION OF THE HEART,

in some instances, be completed.1  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 absorption.
But the mischief about the valves takes place under different
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.2   Hence, as the constant motion of
the valves must tend to keep up such a condition, and as the
irritability 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 experience 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 by all the  general and physical
signs of endocarditis, and the valvular murmur was most
intense.  Nevertheless, on the rapid subsidence of inflamma-
tion, the bellows-murmur gradually ceased.   In two of these
cases the sound commenced so suddenly, increased so rapidly,
and  was accompanied  by such  well-marked general  and
local symptoms of carditis, that there could be no more doubt
  1 For some excellent remarks oa this subject, see my friend Dr. Orme-
rod's' Gulstonian Lectures.'
  2 This was beautifully exemplified in the course of Dr. Hope's experi-
ments 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 been irritated. 
ITS SYMPTOMS AND PROGRESS.
149
as to the  occurrence  of inflammation, and of some deposit
or thickening as the result of that inflammation, than would
attach to any fact  announced through the stethoscope, but
not submitted to ocular demonstration.   Doubtless the mur-
mur in each of these instances is explicable, on the supposi-
tion that  the valves were  merely inflamed and swollen, or
that lymph  had been effused 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.1
   Without pausing to enter more fully  into details respect-
ing the changes induced by endocarditis, I will at once pass
on to the next part of the subject,  and will endeavour to
point out the  natural  connection  subsisting between  the
structural alterations  caused  by exocardial and endocardial
inflammation, and  the various physical signs by which, dur-
ing life, we are able to detect their existence, and to trace
the various steps in their progress.  Here,  again, to facilitate
explanation,  I wall  first suppose inflammation of the investing
membrane of the heart to take place, without the concur-
rence of endocardial mischief, and will then trace the course
of an  attack  of endocarditis  occurring  independently of
pericardial inflammation.
   Before this, 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
  1  Three other sources of this adventitious valvular sound might be sug-
gested :—lstly, the anaemic condition of the patient; 2dly, the increased
force of the heart's action, combined with some disproportion between the
size of its cavities and the orifices of the aorta or pulmonary artery; 3dly,
the irregular contraction of the structures connected with the valvular appa-
ratus, consequent on the morbidly exciting condition of the blood.  Neither
of these explanations, however, seems applicable to the murmur, in the
cases in question.  For, in the first place, the patients had not been subject-
ed to depletion, neither were they by any means anaemic, 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  acting quite as rapidly and forci-
bly ; and 3dly, had it been due to irregular contraction of the structures
connected with the valves, and not to organic mischief occurring in the
valves themselves, it should have evinced some irregularity, both as to its
character  and continuance, whereas it remained constant, and of the same
character throughout, though steadily increasing in intensity. 
 150     RHEUMATIC INFLAMMATION OF THE HEART,

 root of the large vessels, is reflected on itself and forms a
 close sac.   This sac is termed the pericardium.   On its in-
 ternal 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 beart.   But, in disease, the condi-
 tion 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 effused 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 creak-
 ing 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 invariably a to-and-fro sound, accompanying
 the whole of the heart's action, and superadded to its natural
 sound.1  From the position of the parts in which it takes its
 origin, this sound is superficial and seems near to the ear, and
 this, among other  things, serves  to distinguish it from the
 double bellows-murmur, which is  pathognomonic of valvular
 disease.  Another peculiarity attaches to this sound.  Un-
 like 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 which 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 the interposed lymph,
  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. 
ITS SYMPTOMS AND PROGRESS.          151
or from their total separation by the effusion of a large quan-
tity of serum.  In the former case,  the cause of its cessation
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  sur-
faces 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 endeavour  to  ascertain wdiether its disappearance
be  due to excessive effusion, or to adhesion of the two layers
of the membrane, as, if it be due to the former cause, it would
be  a fatal mistake to slacken in our efforts to arrest the dis-
ease, 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 pro-
duction of a dull sound on percussion in the praecordial
region.  In the normal condition the praecordial dulness 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 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 previously furnished a well-marked resonance.
Sometimes this dulness 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 extend  over
almost the whole of the anterior surface  of the chest.  Some-
times, indeed, increased praecordial dulness may  be occa-
sioned by old standing 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 ab-
sence, however, must not be regarded  as certainly indicative
of the absence of effusion, as the dulness which would other-
wise have  resulted from  the  presence  of effusion may be
masked by the intervention of a portion of emphysematous 
152     RHEUMATIC INFLAMMATION OF THE HEART,

lung.  In such a case the chest would yield unusual  reso-
nance.
  Thus, then, if the  cessation  of the friction-sound be de-
pendent on distension 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 dulness be
extended, and so also will the  heart's action become  more
and more embarrassed, 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 the adhesion of the
two  layers of membrane, for as absorption progresses, and
adhesion takes place,  the praecordial dulness  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  pericar-
dium that a friction-sound is no longer audible.   In hospital
practice  patients often are not  seen until after the stage of
attrition has passed away; and even in private practice, cases
sometimes  occur, in which,  either from the rapidity  with
which effusion has taken place,  or from the absence of pain
and other general symptoms of cardiac distress, the  stage of
attrition  is entirely overlooked. In  these instances percus-
sion  is peculiarly valuable; it affords information not other-
wise attainable.  I have known praecordial dulness, for  days,
the only  physical sign of the mischief which had occurred,
and taken conjointly with the distance, feebleness, and irreg-
ularity 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 fremis-
sement 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  carti-
lages 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 which is conveyed by the
friction-sound to the ear.  Its appearance and its disappear-
ance are  also  regulated by the same circumstances on which
the commencement and the cessation of the friction-sound 
ITS SYMPTOMS AND PROGRESS.
153
depend,  but,  unlike  the  friction-sound, it is by  no means
always, or, indeed, generally present.  In every case accom-
panied 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 were, 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 pericarditis to the production of this
tremor, then is the infrequency of its occurrence at once ex-
plained ; as is also the fact, that it usually accompanies the
whole of the heart's action, whereas the purring tremor com-
municated 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.  When-
ever 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 move-
ment will be perceptible  on the  chest.  This,  I  believe, is
attributable solely to the  difference in the amount and char-
acter of the effusion.   For as  the undulation  is  a motion
communicated to the  parietes of the chest by the movement
of fluid in the pericardial 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 undulation, 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
pericarditis, is the peculiar sound of friction I have endeav-
oured to describe;  superficial in  its situation; audible, per-
haps, over a considerable  surface of the chest, but inaudible
along the aorta  or large vessels; varying in its tone accord-
ing to the nature and  amount of the effusion, but almost al-
way s preserving  its distinctive character of a to-and-fro sound,
produced by the rubbing  of two  roughened  surfaces  upon 
 154    RHEUMATIC INFLAMMATION OF THE HEART,

 each other.   In any case in which this has once been heard,
 there cannot be a doubt as to the existence of pericardiac in-
 flammation ;  the  only question which can arise, is as to its
 progress and mode of temiination.  And here again we derive
 the greatest assistance from a careful study of the physical
 signs.   If the  friction-sound cease after  a short  existence,
 and, coincident with its cessation, we find  decreasing dulness
 in the praecordial  region, increasing steadiness in the heart's
 action, and clearness and loudness of its sounds, the progno-
 sis 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 fric-
 tion-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 prog-
 nosis  should  be given according^.  If, again, the friction-
 sound disappears at an early period of the attack, and at
 the same time we discover  increasing dulness in the cardiac
 region,  and find  the heart's impulse  becoming  gradually
 weaker and more irregular, its sounds more feeble and dis-
 tant, and  the pulse fluctuating or intermittent, then are we
 made aware  that the cessation of the sound  is referable to
great  effusion into the sac  of the pericardium, whereby the
heart  is greatly embarrassed; and as this is always an unfa-
 vorable 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  decreasing, 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 commence-
 ment  of disease.  In some, though by  no means in all, re-
 spects, the signs of endocarditis are equally satisfactory.  If
 we know the previous 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 sit-
 uation where mischief  has occurred, and where  it is  still
 occurring.   Some difficulty, however, may arise in discrimi- 
ITS SYMPTOMS AND PROGRESS.
1.55
nating between those murmurs which are referable to organic
valvular mischief, and those which take their origin in func-
tional  disturbance;  and if we are  unacquainted  with the
previous condition of the heart, it is sometimes  almost im-
possible to say whether a murmur results from existing endo-
cardial 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 diag-
nosis, 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
it is taking place, we generally prove unsuccessful in arrest-
ing its progress, until it has produced some permanent le-
sions.  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  imper-
fectly  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 degree 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 cavi-
ties 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 ventricle were not dilated, and its walls not
thickened'—than it  would be if a much  smaller amount of
  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. 
156     RHEUMATIC INFLAMMATION OF THE HEART,

blood were to be driven less forcibly past the same  obstruc-
tion ; 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 it has been supposed to  resemble the
sound  of rasping  or sawing, and in some  cases it has been
thought like the cooing of a pigeon; but generally it is sug-
gestive 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
apprized 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 blood from  the ven-
tricle,  and must therefore be referable  either to obstruction
at the aortic orifice, or to regurgitation through the  mitral
valve.1  If it be contemporaneous with the diastole  of the
heart, it must accompany the entrance of blood  into  the ven-
tricle,  and must therefore be due either to  obstruction at the
mitral orifice, or to regurgitation through  the aortic  outlet.
But then comes the question as to the means of distinguish-
ing the two systolic murmurs from one another, and  of dis-
criminating 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
  1 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 is somewhat un-
certain.  Should it occur, however, it may generally be recognised by the
fact, that the tricuspid murmur is heard further to the right than the
corresponding mitral murmur, and that disease of the pulmonary semi-lu-
nar valves occasions a murmur 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 ves-
sels. 
ITS SYMPTOMS AND PROGRESS.
157
track of the  aorta, than it is towards 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 prob-
able if the pulse at the wrist be weak.   If, as I have seve-
ral 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 per-
ceptible 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 can no longer be any doubt on the subject, as obstruc-
tion 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 ful-
ness, then is the  disease situated at the mitral orifice.  In
this case, as in the last, the murmur is produced by the  pass-
age  of the blood through the roughened, or the rigid and
contracted valvular opening, and the pulse is rendered irreg-
ular and unequal by the constant variation in the quantity
of blood which, at each contraction of the ventricle, regur-
gitates, 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 of 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,occasioned
by a backward, instead of by an onward current of blood, and
consequently is not  transmitted  to  any extent  along the
the  aorta and 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 frequently 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  distinctly 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 quan-
tity of blood ejected at each systole of the heart be insuffi- 
158    RHEUMATIC INFLAMMATION OF THE HEART,

oient to cause  the aorta 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  different.   Not only will  the sound be loudest  from
about the middle of the sternum, upwards  towards the  base,
instead of downwards towards 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 obstruction,  nor the small pulse  of
mitral obstruction, nor  the unequal and irregular pulse of
mitral regurgitation, but in its most marked and most strik-
ing 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
lack 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, wdiich, at each systole of the
heart, is naturally  imparted to the blood  in the  vessels, is
not sustained ;  the  successive waves are, therefore, short and
abrupt, and hence the pulse is jerking, and gives a sensation
as if successive balls  of blood were being shot suddenly
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.1
  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,
  1 In illustration of this, Dr. Watson details the particulars of a very re-
markable 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 uncomfortable 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. 256, 1st ed.) 
              ITS SYMPTOMS AND PROGRESS.           159

even by an  unpractised  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  coinci-
dently with inflammation  of the mitral valve, and then
a deep-seated systolic bellows-murmur, 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 di-
astolic  murmur,  and occasionally a  systolic  mitral mur-
mur 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 diasto-
lic murmur, occasioned partly  by mitral obstruction, and
partly by  aortic regurgitation.  Difficulty  also repeatedly
arises from the fact that one  morbid sound  may be so loud
and prominent  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 charac-
ter and locality 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 diffi-
culties 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 endocar-
dial or exocardial mischief,  and it is only by the variation 
160     RHEUMATIC INFLAMMATION OF THE HEART,

in the character of the sound observed in the course of oft-
repeated examinations, conducted while the patient  is in
different positions, that it is possible to arrive at a correct
conclusion.
   So, also,  it  sometimes  happens  that  an ill-developed
indefinite sound, having its  origin in the heart  or its mem-
branes,  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  in-
stantly  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 reference to the appearance of the patient,
to the treatment which has  been adopted, to the nature of
the symptoms by which the accession of murmur has  been
accompanied, and to 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 position 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 dyspinra, by fluttering or irregu-
larity 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 inflam-
mation, will  not foil to give a significant interpretation to
praecordial pain and increased cardiac action ; whilst, on the
other hand, he  will not over-estimate the importance of a
systolic  murmur, if it occurs in a pale and weakly person
who has been sweated profusely, or has undergone venaesec- 
ITS SYMPTOMS AND PROGRESS.
161
tion, more especially if it be unaccompanied by pain, and be
heard most distinctly in the track of the pulmonary artery.
  Thus, by paying careful attention to the circumstances by
which each case is characterized, wTe may generally arrive at
a correct conclusion, and if we are  sometimes unable to do
as much as might be wished towards  arresting the progress
of the  disease, and repairing the damage it  has occasioned,
it is at least satisfactory 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, whieh  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 directing attention to  the  seat of inflamma-
tion and exciting alarm for the safety of the patient.   As
soon as active mischief has commenced, the whole aspect of
the patient is rapidly changed,1 his countenance, which  only
a short time before had been calm and  tranquil, becomes
anxious, and his whole maimer and  deportment  show but
too clearly that serious mischief has  supervened.  Some-
times he is restless, more generally he lies  quietly flat on
his  back,  and evinces inability or much disinclination to lie
on  his left side.   The breathing,  which before  had  been
unaffected, becomes hurried and shallow, and accompanied
by  a short dry cough;  he complains of uneasiness and op-
pression 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 upwards to the clavicle or the left shoulder.
  These  symptoms are usually more marked in  cases of
pericarditis than in those in which  the endocardium only is
  1 Dr. Hope, 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 im-
pression is conveyed to the spinal cord through the pneumogastric nerves,
and is reflected to the face through the portio dura."
                    11 
 162      RHEUMATIC INFLAMMATION OF THE HEART,

 affected.  Moreover they are apt to vary according to the
 nature of the inflammatory products.   The more solid the
 character of the  inflammatory exudation, 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, cateris paribus, does his pulse
 retain its force and regularity.  On the other  hand, the
 larger the quantity of serum poured out—the more the  peri-
 cardial  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 intermittent his
 pulse.  Indeed,  when  the effusion is very great, whatever
 position  he may have  assumed, whether on his back 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
 indicate the existence  and nature of the mischief; but un-
 fortunately they are not very distinctive, nor are  they very
 constant in their occurrence.  Generally, indeed, when the
 heart is  attacked, some pain, dyspnoea,  irregularity of the
 pulse, or  some other indication  of  existing disease, draws
 attention to the seat of mischief.  But I have repeatedly seen
 cases in which most acute pericarditis has been set up  and
 has continued for some days, without the supervention of any
 symptoms 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.1   Therefore when treating" a case of acute rheum-
 atism 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 cautious and intelligent
practitioner will be aware that  the  absence of such symp-
  1 Cases such as these, in which 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.                                               ' 
ITS SYMPTOMS AND PROGRESS.           163
toms  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, from the acceleration or irregu-
larity  of the  heart's action, or  from any prolongation or
roughness  of its sounds, he has  reason to suspect the com-
mencement of inflammation,—he will at once endeavour to
arrest its progress by active and appropriate treatment.   Nor
will he  rest satisfied with having discovered its existence;
he will 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 anxiously listen, 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 careful percus-
sion in the praecordial region, he will ascertain whether the
effusion  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 affords 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 ex-
pression of the patient, and that excessive restlessness  some-
times supervenes as soon as inflammation  of the heart is set
up.   In some  instances this excitement  of the nervous cen-
tres proceeds to a very much greater extent.   The restless- 
 164    RHEUMATIC INFLAMMATION OF THE HEART,

 ness 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 de-
 lirium of mania, accompanied sometimes by tetanic spasms
 or by convulsions,  which terminate either in extreme exhaus-
 tion or in death by coma.   Such cases have long been recog-
 nised by the profession, and instances in point have been
 placed on record by many  accurate and  observant physiolo-
 gists.1  In many respects they are very remarkable.   They
 present all the symptoms  usually observed in cases of me-
 ningeal or cerebral inflammation, yet are seldom connected
 with any structural change within the  cranium which can
 be  regarded as  indicative  of inflammatory  action.  Some-
 times, indeed, on dissection after death, the cerebral veins
 have been found  gorged,  and  some little serum has been
 discovered effused under the arachnoid, or into the ventricles
 of the brain, but this has been by no means a constant occur-
 rence, and even had it been so,  it would  only have shown
 that in this, as in all other  forms  of violent delirium, the cir-
 culation in the brain is  apt to be interfered 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 generally been far otherwise with the
 heart or its investing membrane.   Serum and recent lymph
 have been found effused into the pericardium, or the endo-
 cardial membrane has been inflamed,  and recent  fibrinous
vegetations have been  seen scattered irregularly over the
 surface of the left auricle, or  deposited,  in the  shape  of
fringes, along the edges  of the valves.   Indeed, so constantly
has cerebral 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 sufficiently frequent to render
it imperative upon every practitioner to examine most care-
fully  into  the condition of his patient's  heart, whenever
 symptoms of flightiness  or delirium begin to manifest them-
selves ; but it must not  be  concluded, without examination,
  1 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 striking cases of this sort are detailed in Cap. X, of this
Treatise. 
ITS SYMPTOMS AND PROGRESS.
165
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  inflammation ;  more fre-
quently in connection with pneumonia  or  pleuritis ; and
sometimes, though rarely, without any local internal inflam-
mation.  In these cases, again, the stethoscope affords inval-
uable assistance, inasmuch as it enables us to ascertain 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 envelopes,
whilst, 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 sym-
pathetic of the cardiac or pulmonary mischief, and may sub-
side coincidently with its cessation.1
  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 inflam-
mation of the joints, and possibly also, in some rare instances,
without the  concurrence, from first to last,  of any active
articular symptoms: it arises  less frequently towards the close
of the disease, when tending  to a favorable termination, than
it does at its  beginning or  during its progress.   It super-
venes most frequently in acute attacks of the disease, more
especially when inflammation attacks many joints, and mani-
fests  a  disposition to  shift its quarters.  It is  much more
commonly met with in the  young than  in those more  ad-
vanced  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
affected, than  in those who suffer principally from synovial
inflammation.   As the general symptoms  of its accession are
variable and uncertain, and are sometimes altogether absent,
the physical signs, which 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,
throughout its course, the physical  signs should be carefully
  1 For full particulars regarding the cerebral symptoms which occur in
connection with rheumatism, see Cap. X, of this Treatise. 
166    RHEUMATIC INFLAMMATION OF THE HEART.

attended to, as affording the only certain evidence  as to the
action  of the  remedies and the  progress of  the disease,
whether towards a  favorable or unfavorable termination.—
Ceteris paribus, the prognosis  should be more unfavorable
in cases accompanied by a  copious effusion into the pericar-
dium, with  great irregularity of the  heart's action, than in
those in which  a smaller quantity of serum is  poured out,
and the heart is less embarrassed; more guarded in those ac-
companied by much constitutional 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 respira-
tory organs are unaffected; and much more unfavorable in
cases complicated by cerebral  disturbance, than in those in
which the intellect remains unclouded.
   The  subjoined abstract of 16 cases of acute  rheumatism
which proved fatal in St. George's Hospital, under the care
of the physicians, during the six years ending Dec. 31, 1S50,
will 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.1
   The ages  of the patients  were thus distributed:
Fatal 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 o	2 7 3 4
	8	8	16
  The particulars of these  cases  are  given  below.  One
other case, which occurred  in the person of a man, aet. 27,
proved fatal, in the  year 1846, but, as no post-mortem ex-
  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 histories of
those which occurred prior to May, 1848, are reported by myself; of those
which occurred subsequently to  that date, by my successor, Dr. Barclay,
the present Medical Registrar of the Hospital.  The post-mortem appear-
ances are recorded by Mr. Prescott Hewett, Mr.  G. D. Pollock, Dr. Hand-
field  Jones, Mr.  Gray,  and Mr. Holl, the successive  Curators of the
Museum. 
FATAL CASES.                  167
amination was made,  I have omitted  all mention of the
symptoms during life.

                          History.

   Case i.—Mary Ann Harrison, aet. 14.—No previous attack
of acute rheumatism.
   Ailing 13 days.   Redness and swelling of the joints, and
pneumonia,  13 days before her death.
   Pericarditis and endocarditis 4 days.
   Occasional  delirium, and choraic twitching of the volun-
tary muscles,  3 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 discov-
ered by the  microscope. There were no true pus-globules.
   In the Pericardium  was serum, with large  quantities of
recently effused  lymph, which here and there had formed
slight adhesions  between  the two layers of the pericardial
membrane.
   The Mitral and Aortic Valves were red and swollen, and
presented,  on their surface  and edges  of contact,  recent
fibrinous vegetations of a pink colour.
   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.
                         History.

  Case n.—Frances Webster, aet. 18.—One previous attack of
acute rheumatism 3 years ago.
  Ailing  51  days.  Inflammation  of the joints, 44  days
before her death.
  Pericarditis and endocarditis, 43 days.
  Pleurisy and pneumonia, 30 days.
  Slight peritonitis, 4 (?) days. 
 168    RHEUMATIC INFLAMMATION OF THE~HEART.^

                 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.
   Mitral  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 smaller quantity.
   Right Lung inflamed in  the lower  part; the  remaining
parts 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 in.—Thomas Howship, aet. 16.—No previous attack of
acute rheumatism.
   Suffering  12 months from an eruption, resembling ich-
thyosis, on the legs.
   Redness and swelling of the joints supervened  suddenly
11 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
diarrhoea, which ceased immediately on  the  appearance of
the articular symptoms.
   Inflammation of the kidneys, 5 days. Pericarditis, 4 days.
Double pleurisy, 4 days.
   Occasional delirium and slight opisthotonos, 2 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. 
FATAL CASES.
169
   Valves healthy.
  Recent Adhesions of the Pleura at  the lower part on either
side.
  Lungs congested, but still crepitant.
  Kidneys  congested.  Mucous  membrane  of their pelvis,
infundibula, and calices, inflamed and covered with a large
quantity of recently effused lymph.
  Liver and other Viscera healthy.
                         History.

   Case  iv.—James  Palmer,  aet.  27.—One previous attack
of acute rheumatism 18 months ago, and palpitation ever
since.
   Rheumatism, with occasional redness and swelling of the
joints,  2 months,  for  which  he  was admitted into  the
hospital.
   Slight papular cutaneous eruption 20 days before death.
   Rigors, with alternate diarrhoea and vomiting, followed
by great increase of the rheumatic symptoms, and relief of
the sickness and purging, 4 days.
   Erysipelas of the face, 2 days.  Delirium, 1 day.

                 Post-mortem Examination.

   Joints.—Right knee and left wrist contained a large quan-
tity of viscid fluid mixed with lymph and pus.   The synovial
membrane 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 vascu-
larity, 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 ad-
hesions, 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. 
170     RHEUMATIC INFLAMMATION OF THE HEART.

                        History.
  Case v.—Jane Laives,  aet.  16.—Had an attack of acute
rheumatism 10 weeks ago,  followed by irregular rheumatic
pains, which have continued ever since.
  Second attack ushered  in by rigors, followed by inflamma-
tion of the joints, 23 days before her death.
  Pericarditis, from 17 to 23 days?
  Pleurisy, 11 days.

                 Post-mortem Examination.
  Joints.—Botdi knee-joints were examined, but no traces of
inflammation were found remaining.
  Pericardium enormously  distended by serum tinged with
blood,  and  containing  masses 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 adhe-
sions with each other at the posterior surface and at the apex
of the heart.
  Endocardium on  the  left side white and opaque, but with-
out 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 wdxite corpuscles
in its structure.
   Other  Viscera congested,  but healthy in structure.
                        History.
  Case vi.—Edward Jeijnes, aet. 27.—No  previous attack of
acute rheumatism.
  Had scarlatina 3 months ago,  and had never been well
since.
  Redness and swelling of the joints supervened 6 days be-
fore death.
  Insensibility and stertorous breathing  came on while he
was in a vapour bath, and he died in about 20 minutes. 
FATAL CASES.
171
                 Post-mortem Examination.

  Joints.—Healthy in  appearance.   Unusual  quantity  of
synovia in the elbow-joint.
  Cranium.—Membranes healthy.  Brain hot unusually 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.
  Heart somewhat dilated, and its muscular structure flac-
cid.   Walls of left ventricle thinner than natural.  Valves
quite healthy.   Endocardium deeply blood-stained.  Blood
fluid, thick and  dark-coloured.
  Lungs congested and  discoloured, and  somewhat emphy-
sematous anteriorly.  Otherwise healthy.
  Spleen pale, soft, and pultaceous, and somewhat larger
than natural.
  Kidneys and other Viscera healthy.
                         History.

  Case vn.—Sarah Woodason, aet. 29.—One previous attack
of acute rheumatism 10 years ago.
  Frequently  suffered  from  wandering rheumatic pains
during last 10 years.
  Long out of health, suffering from leucorrhoea and relaxed
sore throat.
  Repeated rigors, followed by very severe wandering pains,
with profuse acid perspirations 23 days before her death.
  Inflammation of the joints 18 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
quantity of the synovial fluid, mixed with a small quantity 
172     RHEUMATIC INFLAMMATION OF THE HEART.
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 3 inches in length, and a quarter of an inch broad at
its greatest diameter.
  Pericardium contained a small quantity of serum, and at
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 easily be peeled off.     •
  Valves.—Mitral valves somewhat thickened.  Aortic valves
healthy.
  Slight recent  adhesions of the Pleura 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 vm.—George Smith, aet. 16.—One previous  attack,
complicated by inflammation of the heart 2 years ago.
  Present attack commenced with wandering pains in the
limbs 21 days before his death.
  Increase in the severity of the pains 18 days.
  Profuse rheumatic perspiration, but no redness or swelling
of the joints.
  Pericarditis, 18 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 hypertrophied.
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 chords
of the mitral valve were remarkably developed.
  Lungs congested, but crepitant and healthy.
  The Kidneys, Liver, and other  Viscera, healthy. 
FATAL CASES.
173
                         History.

  Case  ix.—Richard Huntley, aet.  17.—No history of any
previous attack of rheumatism.
  Redness and swelling of the  joints commenced 27 days
before death. ,
  Pericarditis between  18 and 27 days.   The exact period
uncertain.   It existed at the time of his admission into the
hospital, when also he was in a state of salivation.
  Endocarditis.   Exact period of its commencement uncer-
tain.
  Pneumonia about 12  days.
  Pleurisy about 5 days.
  Large abscess  in the left axillae, 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 by a thick
layer of recent  lymph, some of which was deeply blood-
stained, and some  of which also was becoming organized.
and presented 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.
  Right Lung gorged with frothy serum, and at its lower
and back  part were  several patches of hepatization.
  Left  Lung was also  gorged  with frothy red serum, and
presented several patches of red hepatization.
   The  Right Kidney appeared  somewhat coarse;  the Left,
congested, but healthy.
   The  Liver, Spleen, and other  Viscera, congested,  but per-
fectly healthy in structure. 
174     RHEUMATIC INFLAMMATION OF TEE HEART.

                         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 afterwTards.
   Wandering  rheumatic pains five weeks and a half before
death.
   Redness and swelling of the joints began  23 days before
death.
   Pericarditis, 16 days.   Endocarditis, 15 days?
   Bronchitis, 15 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 valve, on the auri-
cular 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 Pleura 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 con-
gested, but healthy.
                        History.

  Case xi.—Elizabeth Adams, xi. 30.  No previous attack of
acute rheumatism.
  Present illness began, without previous  indisposition^?),
by redness and swelling of the joints, 12 days before death.
  Pericarditis and endocarditis from 9 to 5 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. 
FATAL CASES.
175
  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.
  Pleura and Lungs healthy.
  TJver 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 xn.—Catherine Doyley, aet. 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 18 days before her death.  Inflammation of the
joints only lasted two or three days.
   Pericarditis and endocarditis 13 days before death.
   Pleurisy 5 or 6 days.  Sank gradually.

                  Post-mortem Exa m ination.
   Joints not examined.
   Pericardium.—Thickly  covered on  its free  surface by a
coating of recent lymph, which had contracted tolerably firm
adhesions, gluing the visceral and parietal layers of the mem-
brane together throughout their whole extent, excepting on
the outer side corresponding  to  the outer side  of the 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
contact, 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.
   Right Lung infiltrated by frothy serum.
  Partial  old adhesions of the  left pleura, and effusion of
serum  and recent  lymph  at  the lower part  of the pleural 
176     RHEUMATIC INFLAMMATION OF THE HEART.

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 xm.—John Hodges, aet. 21.  No  history of any pre-
vious attack of acute rheumatism.
  Seized with pain in the head, and wandering pains in the
limbs, 8 days before death.
  Redness and swelling of the joints began 5 days before his
death.
  Heart symptoms, 5 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 4 ounces of an opaque fluid,
in which floated numerous shreds of lymph.   The free sur-
face  was covered by a coating  of recent lymph, which, on
the anterior  surface of the heart, had begun to contract ad-
hesions.  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. 
FATAL CASES.
177
                         History.

  Case xiv.—Ann Amess, aet. 21.—Slight rheumatism one
year ago, but no previous acute attack.
  Inflammation of the joints 17 days before death.
  Palpitation and pain in the chest,  10 days.
  Miliary eruption of sudamina, 7 days.
  Delirium, more or less, 3 days ; violent, 12 hours.

                 Post-mortem Examination.

  Joints.—The synovial membrane of  both knee-joints was
highly vascular and red.   In the  cavity of the joints was a
quantity 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  Mindenhall,  aet.  12.—Several previous
attacks of acute rheumatism : one when he was 6 years old.
  Ailing,  18 days.
  Inflammation of the joints, 15 days.
  Palpitation and endocarditis, at least 11 days.
  Pericarditis, 7 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.
                12 
178     RHEUMATIC INFLAMMATION OF THE HEART.

   Valves.—Recent  fibrinous  vegetations on the  mitral and
aortic valve.  Old  thickening of the  mitral valve.  Slight
recent thickening of the tricuspid valve.
  Right Pleural Cavity contained several ounces of serum,
mixed with recent lymph.
  Lungs,  congested throughout; in the lower half on either
side inflamed, and in parts in a state of grey 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 14  days
before his death.
  Delirium with much tremor, more or less, 3 days.   Furi-
ous 1 day.
  Pericarditis a few hours.

                 Post-mortem Exa m ina tion.

  Joints.—Right sterno-clavicular  articulation softened, and
surrounded by thick yellow pus.   Pus also in the left elbow
and  in the right nlno-carpal articulation, and  extending
along the tendons.
  Membranes  of the Brain congested.   Slight effusion in the
sub-arachnoidean 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 Pleura 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 con-
trolled, 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 pericarditis, to induce absorption  of
the matters effused, and to prevent adhesion of the two lay-
ers  of the pericardium?  Or, when inflammation of the en-
docardium 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 his subsequent
career will in most cases be short, and exceedingly distressing.
Before many years have elapsed, he will begin to  suffer from
asthma and  palpitation, as  the 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 adhesion of the two layers of the peri-
cardial membrane, the result ef the former cardiac inflamma-
tion.
  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 
 180     RHEUMATIC INFLAMMATION OF THE HEART.

 bound not only to employ active measures as soon as it has
 made its appearance, but to use every means which experi-
 ence 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  attack, as the whole subject re-
 solves itself into a question  respecting the best treatment for
 the alleviation of rheumatism, and this  has been  fully dis-
 cussed in a previous Chapter.   There is one method of treat-
 ment, howrever, 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 s}rstem under
 the influence of mercury, it is possible  to ward off cardiac
 inflammation.  No statement, however,  con be more erro-
 neous, or more mischievous: erroneous, because pericarditis
 is frequently set up whilst the system is  fully under the in-
 fluence of mercury; mischievous, because ptyalism forms a
 grievous addition  to  the miseries  of the disease,  very fre-
 quently causes excessive depression, and thus tends to  give
 an unhealthy character to  the inflammator}^ 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.   Cal-
omel, when given during the progress  of inflammation  in a
healthy person, is  assuredly one of the most powerful aux-
iliaries ; 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 conducive to  recovery.
 In five instances I have seen acute pericarditis supervene at
 a time when the patient was profusely salivated, and in every
 case the ptyalism  appeared to  operate prejudicially.1   The
  1 " I 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 young woman, who was brought some five or six years ago into St.
George's Hospital (shortly before her death), profusely salivated in  sequel
of rheumatic fever." (' Observations on the true Character of Acute Rheum-
atism," by Dr. Wilson, Senior Physician to St. George's Hospital.  ' Lancet'
for 1844, vol. ii, p. 254.) 
ITS TREATMENT.
181
inflammation partook but slightly of the adhesive character,
the pericardium  became enormously distended 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.  Endocarditis 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 mercurial action
had existed.
   But although  calomel and opium have no power of pre-
venting the access of cardiac inflammation, those remedies
which fulfil the purpose of relieving the general symptoms
of the  disease  are,  to  a great  degree, safeguards for  the
heart; whatever is the best  treatment for an uncomplicated
attack of acute  rheumatism, the same affords  the surest
guarantee against its various complications.   Whether venae-
section, or guaiacum, or opium, be  employed; or whether
colchicum, calomel, alkalies, or purgatives, the heart will be
protected from,  or exposed to, the risk of inflammation,
according as each  remedy  is administered  judiciously.  If
venaesection 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 favour
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 turbulently,  and
secretion  is defective or suspended, its omission will as cer-
tainly expose the heart to mischief, by leaving it in a state of
excitement, which might have been mitigated or subdued by
the aid of a moderate blood-letting. And so with every remedy
which can be named.  Its virtue in warding off cardiac inflam-
mation varies according to the circumstances under which, and
the judgment with which, it is employed, and coincides ex-
actly with its virtue in alleviating the  general symptoms of
the disease.  The treatment of 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 their
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,  be- 
182     RHEUMATIC INFLAMMATION OF THE HEART.

fore  we see our  patient,  inflammation of the  heart or its
membranes has commenced, and sometimes, even in spite of
our efforts, it will supervene whilst our patient is under
treatment.  Therefore 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 circumstances, we can seldom, if ever,
do all we desire for our patient's recovery; though we can
seldom or ever prevent his heart sustaining some permanent
damage, we may at least, by early  and appropriate treat-
ment, do much towards 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 the circulation, we  may
greatly  defer  the day, which sooner or later is certain to
arrive, in which the heart, suffering from the effect of suc-
cessive 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,
suffocation, 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 must  obviously be corrected as far as
possible.  Secondly,  there is the local inflammation ; and
this must, at all hazards, be subdued, if we hope to save our
patient from immediate death.  Thirdly, there are  the  pro-
ducts of inflammation ; and these must be got  rid of, if we
wish to prolong his days, and to save him from the conse-
quences of a  damaged heart.  In a previous  Chapter the
treatment which  is best  adapted to fulfil the 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  absorbents.
  Of all the remedies for the cure of rheumatic inflamma-
tion of the heart, venaesection is that most generally adopted.
M. Bouillaud  has employed it very largely in France ; and
even here it has numerous and strenuous advocates. Observa-
tion, 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. 
ITS TREATMENT.
183
But in general it has  afforded  very little relief.1   It  has
usually failed in subduing the pain, and has produced only a
temporary impression on the pulse.   On the other hand, the
arguments against its indiscriminate employment are nume-
rous, 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 forty-seven cases, of which
I have notes, in which it was not  employed, one only proved
fatal, and  this was  a case  of  pericarditis, wdiich occurred in
a weak debilitated person, and was complicated by extensive
inflammation of the pleura.   And, lastly,  it is often preju-
dicial  to the patient by exhausting  his strength, rendering
him liable to relapses, and altogether protracting his recov-
ery.  There also appears strong reason for doubting whether,
as  suggested by Dr. Watson, " bleeding to such  an extent
as  to bring the heart's action to a pause in deliquium"  may
not tend to favour the deposition of fibrin upon the  valvular
apparatus.
   General bloodletting, then, should be employed in rheum-
atic carditis, under  precisely the same circumstances as in
cases of acute rheumatism uncomplicated by cardiac inflam-
mation.  As a remedy to be exclusively  relied upon, it is
quite  unavailing, and often  extremely dangerous : as an ex-
pedient to be employed in aid of other remedies, it is occa-
sionally of the  greatest service.   If  a patient be robust and
plethoric, with a pulse characterized by* extreme fulness or
hardness, it may be had recourse to with the greatest advan-
tage, and may be repeated until some impression is produced
 on the circulation.   In such persons it assists in allaying the
 inflammation, and favours the action of mercury and other
  1 I am glad to quote, in confirmation 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 anti-
phlogistic.  I have seldom employed venisection 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 repeated 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 spirit, says, " My experience leads
me to value ver}1- lightly the efficacy of general bleeding in inflammation of
the heart" ; and Dr. Watson reports, that he '• seldom opens a vein in these
cases." 
 184    RHEUMATIC INFLAMMATION OF THE HEART.

 remedies.  But in ordinary cases its employment is unneces-
 sary, 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 irrita-
 ble and excited heart, and to favour, as I believe, the forma-
 tion of fibrinous dej)osits 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,
 yet local bloodletting 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 im-
 mediate 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 repeated general bloodletting.  Not unfre-
 quently the praecordial pain ceases, the heart's sounds become
 clearer, and the  pulse  softer, even while the leeches are
 doing their wrork.
   It is sometimes a question whether leeching or cupping is
 the more appropriate remedy in these cases ; and  some per-
 sons recommend the  employment of the  former,  whilst
 others  as  strenuously advocate the latter.  My own expe-
 rience inclines me to give a  decided preference to leeches.
They are quite as e*sy  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 con-
dition of the heart, the least pressure and  the least percus-
 sion cannot fail to be productive  of mischief;  and, although
this difficulty may be in some measure overcome by apply-
ing the cupping-glasses between the left scapula and the
vertebral column, I still incline  most  strongly to  leeches;
for I 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 cup-
ping, blood is often abstracted as copiously, and almost as
rapidly, as by venaesection 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 afford 
ITS TREATMENT.
185
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
venaesection from the arm, or by cupping as ordinarily prac-
tised.  If the force and fulness of the pulse be such  as  to
require  bloodletting for its relief,  or if  the  patient be  so
plethoric as to render it desirable to let blood with the view
of expediting the action of remedies, then bleeding from the
arm is the more appropriate treatment.   If, on the contrary,
the patient be pale and weakly, and the pulse not more than
ordinarily forcible, then, if bloodletting be deemed advisable
for the relief of the praecordial pain  and  anguish, leeching,
and not general bleeding,  should be had recourse to.   Cup-
ping should be reserved for those cases  in 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 rheum-
atic carditis.  Powerfully  antiphlogistic in  the  influence
it exerts, it assists in moderating the intensity, and in limit-
ing the  extent, of inflammatory action; and having done so,
it  operates  as  bloodletting does not, it  promotes the ab-
sorption of the matters effused.  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
unnecessary 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 mis-
chief:  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 difficult of removal, so that
no time must be lost in pressing to its fulfilment the treat-
ment considered most efficacious  against their  extension.
For this purpose mercury, of all known remedies, is that on 
186     RHEUMATIC INFLAMMATION OF THE HEART.

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 effect pro-
duced  by bloodletting ;  it  calms the violence, alters  the
character, and circumscribes the limits of the local inflam-
mation ;  it  stimulates the absorbents to  the business of
repair, and promotes  the  continuance of the natural secre-
tions at  a  time when they  are checked, and wTell-nigh  sus-
pended, by the shock the system has sustained.
  But to ensure 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 running off. by the bowels, may be
given every four hours,  and,  if it be considered  desirable
still further  to  hasten  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 on 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 murcurial  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 will be  displayed.  But as soon as sali-
vation has commenced, and even  sooner in some instances,
the  symptoms manifestly improve ;  the  pain and anguish
begin  to subside,  the pulse becomes quieter and  steadier,
and 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 praecordial
dulness, denotes the absorption  of fluid  from the pericar-
dium,  whilst, 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 amendment produced until after ptyalism has com-
menced, that I cannot doubt  as  to the  cause of the  im-
provement. 
                     ITS  TREATMENT.                 1S7

  Iii  this, as  in  all  other serous inflammations, it  will
sometimes be found  difficult to obtain the  constitutional
effect of  mercury.   It may be freely  administered  for  a
considerable  time,  and may be  carefully guarded 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  exhibition  is  useless.
As  opium, when  acting  beneficially in delirium  tremens,
and  acute rheumatism, may be given  in  enormous  doses
without occasioning either stupor or constipation ;  so,  when
the  constitution  is sound, and  inflammation violent and
extensive,  mercury,  whilst exercising  a  most  beneficial
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 ques-
tion,  whether the  difficulty experienced in  producing sali-
vation may not,  cateris paribus,  be taken 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 my experience,
the difficulty  of  inducing salivation  has varied, cateris par-
ibus,  according as  the patient has been strong and healthy,
the inflammatory symptoms unusually high, and the inflam-
mation extensive, and of that peculiar character which tends
to the effusion of plastic and highly organizable lymph.
  Mercury, though generally beneficial in rheumatic carditis,
is not equally so in all constitutions.  In robust  and habit-
ually healthy persons, it  seldom gives rise to much consti-
tutional irritation or depression, and when the inflammation
is extensive, it produces its specific action  slowly, and acts
most beneficially  on the  course of  the disease.  In  such
cases, therefore, it  can hardly  be employed too  fearlessly
or t6o vigorously.  But  in the weakly, the irritable, and
the unhealthy, its constitutional effects  often supervene rap-
idly,  are extremely violent in their character, and, in some
instances, frightfully depressing; and hence it is productive
of injurious consequences by favouring a tendency to serous
or suppurative, instead of to adhesive, inflammation.  To
such, therefore, it cannot be administered  too  cautiously.
In the one set of  cases it is essential for the arrest of in-
flammation at a time when life is threatened by its extreme
intensity ; and the object  being to produce a forcible im- 
188     RHEUMATIC INFLAMMATION OF THE HEART.

pression on the disease  as  rapidly as possible, it  can hardly
be given too largely or  pushed too vigorously.   But in the
other, the system is readily depressed, and when depressed,
is  prone  to set up  unhealthy inflammation.1   Therefore,
although it may sometimes be 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 repeated 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  admin-
istration should be suspended.
  Some persons have lately attempted to undervalue the
curative influence of mercury in pericarditis,2  and  others,
though not denying  its efficacy in many forms of inflamma-
tion, have yet contended that the cure of pericarditis, occur-
ring in connection with  rheumatism,  may be safely intrusted
to other remedies.3  Now  although,  as already stated, I do
not counsel the discriminate employment of mercury, and, in
some  rare  instances, do  not administer it even in the most
cautious manner, 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, more especially when the kidneys are
in a state of disease.   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 constitution, nothing is of
greater service than the remedy in question.  No such case can
be safely treated without its administration. Recovery may,
in certain instances, take place without it, as, indeed, without
  1 This, rit ka>t, I can posi ively assert that, in six cases which have fallen
under  my observation, in which mercurial action has b en accompanied
by much constitutional  depression, the accession of  salivation has been
marked by the disappearance of the to-and-fro sound of pericardial friction,
with coincident extension of the praecordial dulness, and increase in the dis-
tance and feebleness of the heart's sounds, and that the effusion thus une-
quivocally declared has been slowly and with difficulty removed.
  3 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. 6, 1851. 
ITS TREATMENT.
189
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 experi-
ence and observation have supplied  such abundant and un-
equivocal proofs, as of mercury in active serous inflammation.
Its efficacy, however, varies  very remarkably,  according  to
the class of cases in which it is employed, as also to the mode
in which 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 only inoperative, 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 inju-
diciously 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 power-
fully in aid of bloodletting and mercury.  Roused and exci-
ted as the vascular and nervous  systems  are by the violence
of the morbid action, and the pain which attends it, all rem-
edies prove comparatively useless if unaccompanied by the
sedative influence  of this narcotic.   The constant pain, with
the absence  of sleep, and the constitutional irritation con-
sequent thereupon, do more, I believe, to exhaust a patient's
strength, and counteract  the actions essential to his recovery,
than bloodletting and mercury can do to promote them.  In
every case,  therefore, of rheumatic carditis, opium,  in full
doses, is indispensable. It should not only be given in doses
adequate to restrain the purgative action of the calomel, but
in quantity sufficient to assuage the pain and allay the irrita-
bility.  From two-thirds  of a grain to a grain, or even more,
should be given, 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 sedative solution.1
To the weak and irritable, to whom mercury is of little ser-
vice, it proves peculiarly valuable.  It not only subdues pain,
but it allays irritability and procures sleep, and I am satis-
fied  that many of  my patients would have fallen  victims to
  1 I find that, in these cases, the Opium itself is preferable to the Salts of
Morphia. 
190     RHEUMATIC INFLAMMATION OF THE HEART.

the disease, had not  their strength been husbanded by its
sedative influence.
  It is probable, however, that opium exercises some more
directly 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 ob-
noxious to the effect of irritation.  Just as, before cardiac
inflammation has been set up, opium may exercise a sedative
influence on the heart, and may thus render it less prone to
be affected by the irritation of the rheumatic poison, so also,
I believe,  after the  commencement of  the  mischief, opium
may subdue and tranquillize, and thus prevent that excess of
irritation whereby the course  of inflammation is prolonged,
and  its products made to assume  an unhealthy character.
In several instances  of pericarditis in which, in spite of venae-
section and mercury, inflammation has continued unabated,
whilst 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 dis-
ease, has testified to the reality of  the  improvement.  The
same train of symptoms was  also observed in two  cases in
which, from the weak and cachectic condition of the patients,
I was fearful of inducing mercurial action,  and therefore
trusted exclusively to full doses of opium, with alkalies, diu-
retics, and repeated  blistering.  The  sedative  apparently
contributed as much to the patients'  recovery, as it mani-
festly did  to thfeir comfort.
  Another most important remedy in rheumatic pericarditis
is a large blister applied to the chest.  In the early stage of
the attack, more 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 liquid effusion, its virtue
being most unequivocally displayed when the  amount of
fluid is greatest.  In such cases an immediate diminution in 
ITS TREATMENT.
191
the praecordial dulness, together with greater clearness in the
heart's sounds, is often observed as the result of a large and
efficient blister.
  Whilst  applying leeches and  blisters, and in  some in-
stances pushing mercury to salivation, the other general indi-
cations 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 get rid of the
materies morbi to wdiich 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 inflammation.  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 prove emi-
nently 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 its issue, unless  perfect rest be enjoyed, and every cause
of  excitement  carefully  guarded  against.   This  has  been
repeatedly forced upon my attention in the strongest pos-
sible manner.   In  several instances in  which  the  patients
have worked themselves into a state of  excitement, in con-
sequence  of the dread inspired by the thoughts  of being
leeched, or cupped, or bled, every symptom has been aggra-
vated, 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
commencement of active treatment ?
   This question hardly admits  of a definite answer, inasmuch 
 192    RHEUMATIC INFLAMMATION OF THE HEART.

 as the symptoms which mark the accession of carditis are of
 a complex nature, and, moreover, are uncertain and variable
 in their existence.  In  most instances some exocardial fric-
 tion-sound is heard, or some  endocardial murmur accompa-
 nying the heart's sounds ;  and, together with this, there is
 anxiety of countenance, and  praecordial pain and anguish,
 with dyspnoea, palpitation, 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 inflammation are present, even  though
 some of the general signs be wanting.  In  other  instances,
 however, our attention  may  be  called  to  the  sudden ac-
 cession of  praecordial pain occurring coincidently with tur-
 bulence, 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  indication  of existing
 mischief.   What is to be done in  such a dilemma ?  Are we
 to trust implicitly  in the general symptoms,  which are on
 all hands admitted to be uncertain and fallacious, or are we
 to delay taking active measures until the presence of inflam-
 mation has been rendered indubitable by the presence of the
 auscultatory  signs?   The  cautious  practitioner  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
 roughness  wdtli 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  system  is developed.  Indeed,  the
 frequent  occurrence of cardiac inflammation  gives such a
 significance to  praecordial  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 pericar-
 dial 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 further evidence of
inflammation, in  having recourse to active depletion, we
 shall yet do well  to put a few ±aeches on the  chest, and to
 commence  the  cautious administration of mercury, whilst 
ITS TREATMENT.
193
watching most jealously for any indication 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, how-
ever slight the sound may be, the evidence  of mischief is
unequivocal, even though  there be total absence  of  pain
and other general symptoms of cardiac inflammation.  But
it  frequently happens that the sound occasioned  by  exo-
cardial friction is  at  first indistinct, heard only over a small
circumscribed space in the praecordial region, and audible
at one moment, inaudible at another.  Thus, sometimes for
a day or two together, this  abnormal sound will be alter-
nately audible  or inaudible, until  at  length it either be-
comes permanent or ceases  altogether.  In  cases  such  as
this, it would  not  be  right  to  defer all treatment 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 indistinct
and indefinite yet abnormal sounds  so  frequently subside
without  any treatment, that their presence alone does  not
justify our taking any vigorous steps for  their removal;  at
the same time  they  are so suggestive of evil, and  so com-
monly prove the precursors  of  extensive  mischief,  that
some  precautionary treatment should be adopted, and their
course narrowly watched,  in  order that the remedies  may
be pushed more  vigorously should their increase  betoken
active inflammation.
  So,  again, with 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 any 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
prolongation of the systolic sound.  Even this,  if accom-
panied  by  praecordial  pain,  dyspnoea, and  palpitation, is
sufficient  to excite  alarm, and to justify the adoption of
measures for its subjugation,  inasmuch as such a symptom
affords sure evidence of mischief, and is the usual forerunner
                    13 
 194     RHEUMATIC INFLAMMATION OF THE HEART.

 of active inflammation.   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
 consequent 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 meas-
 ure, 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 wdth imperfect closure of the mitral orifice, yet is
 unaccompanied by praecordial pain, dyspnoea, or palpitation,
 or  by any formidable cardiac  symptoms.  In many  such
 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 contraction  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  remedies 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 func-
 tional causes;  and although the superficial position of such
 a murmur, 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  attributable to organic  mischief, still,  if considera-
 ble caution be not observed, it may  be mistaken for a mur-
 mur the result of inflammation, and  treatment  may be
 adopted ill-suited to the circumstances of the case.
  The greatest care, then, is requisite in listening to the car-
diac sounds.  The heart should  be  daily examined, and the
least deviation from health should be noted.  The least pro- 
ITS TREATMENT.
195
longation, or unnatural harshness, or roughness of its sounds,
is  sufficient to excite  alarm, and  the least  suspicion of in-
flammation  is enough to justify some precautionary treat-
ment.   But until the existence of inflammation  is placed
beyond doubt, it is  not  necessary, nor indeed would it be
prudent, to push our measures so vigorously as would other-
wise be deemed essential.   The  remedies  to be  employed
are the remedies for inflammation, but they should be duly
apportioned to the exigencies of the case.
   There is yet  one point which requires notice in connec-
tion with  these  endocardial murmurs.  It is, that during
the convalescence 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 irrita-
bility  about the heart, there is no  pain, and no unusual  pal-
pitation.   Even during convalescence, then, the heart must
be constantly and carefully examined, and on the  first indi-
cation of change in  the character  of its sounds, most active
treatment must be had recourse to; treatment active not in
its essential characters 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, independently 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 experi-
ments on the ass.  The remedies most powerful in prevent-
ing its further  deposition, and in  effecting its removal, are
alkalies and the neutral  salts, with opium, in full  doses, and
mercury, cautiously administered.
   In  every instance in which, after all  active  symptoms
have  subsided,  there still remains much  irritability of the
heart, it is expedient, whilst attending to the general health,
to administer occasional doses of opium and digitalis, and to
apply an  opium or  a belladonna plaister 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, in
great  measure,  guard against those lesions which,  arising
after  all inflammatory action has been subdued, are due to 
196    RHEUMATIC INFLAMMATION OF THE HEART.

the existence of chronic irritation rather than of true inflam-
matory action.
  The following cases will serve as illustrations of the treat-
ment recommended, and  of the share which each remedy
takes in effecting the cure.

  Case  i.1—Fanny Nicholls, a pale-faced girl, aet.  19,  was
admitted into the  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 with increased
severity.   The sounds of the heart were clear ;  but as  she
complained of pain  in the praecordial region, it was judged
expedient  to put her under the influence of mercury, and
the following  pill was therefore ordered :
      ft.  Hydrargyri  Chloridi, gr. iij; Opii,  gr.  i.  M.  ft.  Pilula 6"'
           horis sutnenda.
  January  1st.—The next  day the sounds of  the  heart  still
remained clear, and  there was no increased dulness on  per-
cussion in the praecordial region, but she complained, as be-
fore, of pain in the chest, and the pulse was 120 and stronger;
so it was judged advisable to repeat 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  col-
league,  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 natural praecordial dulness.
Her joints  were still red and swollen ; the gums were as yet
  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 usu-
ally be brought about even by the most judicious treatment. 
ITS TREATMENT.
197
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 alkaline  and opiate
fomentation, and as she did  not  appear to be very suscepti-
ble 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 :

      R.  IL Salinus effervescens c. Potassse Nitratis, gr. xv;
                            Sodae Potassio-tart., Sij ;
                            Tincturse Opii, V\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 dulness in the praecordial region, showing the ex-
istence  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 was very loud, and the praecor-
dial dulness 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 anti-rheumatic properties.
   On the 7th there was very little  alteration in her symp-
toms, except that the urine had become abundant and almost
clear, sp. gr. 1026, and the bowels showed a tendency to re-
laxation.   The blister had  risen well, and was  discharging
freely.  The 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  8th  there was manifest  improvement.  She  had 
198     RHEUMATIC INFLAMMATION OF THE HEART.

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 discharging freely ; there was less extended
dulness  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 unaffected, the pills and the
draught were continued as before.
  On the 9th the* favorable progress of the disease was more
marked.  The dulness on percussion in the praecordial region
was now scarcely more  extended than natural, and the fric-
tion-sound was confined to the base of the heart.  The sys-
tolic 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 mer-
cury, the pills and draught were repeated.
  On the 10th the inflammation of the heart was subdued.
There was no longer any extension of the praecordial dulness,
and no  longer any friction-sound or  endocardial murmur.
The pulse was 84, soft; the urine clear and abundant, and
the tongue much cleaner.  There was neither redness  nor
tenderness of the  gums, but the relaxation of the bowels had
increased, 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, con-
taining 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,  whilst
her bowels were quieted by Dover's powder.  From this time
her convalescence proceeded steadily ;  and when she left the
house, on the 5th of February, her heart was acting regu-
larly, and its sounds were clear and free from  murmur.
  Case n.—Sarah Coivlcy, aet. 23, was admitted into the
Rosebery  Ward of St.  George's Hospital on  the  Sth of
August, 1851,  labouring under  acute  rheumatism  of nine
days'duration.   She had undergone an acute attack of the
disease four years ago, but from that time had remained free
from pain until the commencement  of the present  illness. 
CASES ILLUSTRATING THE TREATMENT.       199
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  dry;  bowels  open;  urine  scanty  and  strong
smelling, high coloured, 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 re-
gion 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  fol-
lowing remedies were prescribed:
    Hirudines x, regioni cordis.
R.  Hydr. Chloridi,  gr. iij ; Opii, gr. j.  M. ft.  Pilula 4,a quaque hora
        sumenda.
    Haustus Potassa?  Nitratis, gjss ; Soda? Potassio-Tart.,  3 ij; Vini Col-
        ehici, m.xv; Tinct. Opii, Tltviij.
    M. ft. Haustus 4tia horis alternis sumendus.
  Fever diet.
   9th.—She dozed  at intervals during the night,  and per-
spired freely.   The next  day the joints were much easier,
and the urine more abundant;  sp. gr.  1028.  The  heart's
sounds, however, 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.

    Rep. Hirudines vj, regioni cordis.
           Repetatur Pilula, 4tu horis.
    Rep. haustus 4"" horis alternis, sed c. Tincturse Opii. Ti\xv.

   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 contrac-
tion of the pupils,  had failed to restrain the purgative action 
200      RHEUMATIC INFLAMMATION OF THE HEART.

of the mercury, and to allay the  irritation tb which  it gave
rise, the pills were repeated only twice a day.   The draught
was continued as  before.
  11th.—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 abun-
dant and clear.  Pulse 116, weak and irritable.  A systolic
murmur still perceptible, though less loud and harsh than it
was yesterday.
  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.  At the
same time, by way of precaution  against a relapse, a pill was
given at night, containing a grain of Opium and 2 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, and all her symptoms showed such decided improve-
ment, 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 convalescent.   However, as she was  very pale, five
grains of the Pilula Ferri C. were given three times a-day, in
addition to the quinine; and this she continued taking up to
the 3rd of September, when  she left the house, her health
being completely re-established.  A slight systolic mitral
murmur, however, still existed.
  Case in.—Harriet Pope, a pasty-faced girl, cct. 17, was ad-
mitted into the Princess Ward 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
Hospital, the feet and ankles alone were affected.  She was 
          CASES ILLUSTRATING THE TREATMENT.       201

perspiring freely;  tongue coated and white;  urine acid, high
coloured, 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 prae-
cordial dulness; but  there was a slight roughness with  the
first sound at the apex of the heart, and an indistinct irre-
gular double murmur, 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 :
    R.  Hydrargyri Chloridi, gr. iij ;  Opii, gr. j, ter in die.
       Haustus Senna) c. Soda) Pottassio-Tart., 3iv, eras mane.
       Ilaust. Potassae Citratis, ^ss;
       Sodse Potas-io-Tartratis, _ej ;
       Vini Colchichi, trixv;
       Liq. Opii Sed. (Battlei), ttlviij; °ta quaque hora.

   Sept. Uh.—The next day she was decidely  worse.   The
pains in the joints were easier, but she had not slept;  her
countenance was anxious, the pulse 140, extremely weak and
irregular, and occasionally intermittent, and she  exhibited ex-
treme disinclination to change her posture.  There was still
no pain at the heart,  but extended dulness on percussion in
the praecordial 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
friction-sound could  now and then be heard 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 xii. regioni cordis et p"stea emplastrum Cantharidis.
      Repetatur pilula 6"", horis.
      Repetatur haustus 6ti8 horis alternis.

  5th.—The next day there were signs of amendment.  She
had slept fairly ; the  pains in the joints were slight, and the
swelling had entirely disappeared; the pulse had  fallen to
120, and was much  more regular; the praecordial dulness
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. 
202     RHEUMATIC INFLAMMATION OF THE HEART.

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 Medicamenta.
   6th.—She passed a  restless night, and the next day ex-
hibited 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
praecordial dulness had again extended itself;  and the pulse
was 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 Medicamentorum.
   7th.—The following day the pain at the heart continued,
and the increase of effusion was manifested by the total ces-
sation  of the friction-sound, by the distance  and feebleness
of the heart's  sounds, which had become almost  inaudible,
and  by the dulness on percussion which  now  extended over
to the  right side of the sternum.  Her countenance was very
anxious; the pulse,  however, 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 abun-
dant.  The gums were still not affected, so mercurial oint-
ment was  applied  to the  blistered surface,   the pill  was
repeated every six hours, as before, and a diuretic draught,
containing  Potassae Nitratis, gr. x, Tr. Scillae,  ttixv, Tr. Can-
tharidis,  ttixx, was substituted for  the saline medicine  she
had hitherto taken.
   8th.—The next day mercurial action  was more decided,
and  she was manifestly better.   Her countenance was less
anxious; the extent of dulness on percussion had diminished,
the friction-sound was again audible, the sounds of the heart
were louder, and the pulse had fallen to  96.   The bowels
were somewhat relaxed.
                 Perstet in  usu haustus diuretici.
               Repetatur pilula bis in die tantum.
                    Opii, gr. j, hora somni.
   9th.—Continued  improvement.  Gums  fully effected.—
Sounds of the heart  clearer, and friction-sound very loud. 
CASES ILLUSTRATING THE TREATMENT.       203
Less extension of the natural praecordial dulness.  Pulse 90,
regular.  Bowels much relaxed, with green mercuriali mo-
tions.
                Perstet in usu haustus diuretici.
                     Omittantur pilulee
                    Opii, gr. j, bis in die.

  From  this time  her improvement  was  steady  and pro-
gressive.   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 treat-
ment until the 4th of October, when, as the endocardial
murmur was no longer audible, and the pulse was weak, a
drachm of  the  Tinct. Cinchonae was added to the draught.
When she  was able to move easily in bed and shift her posi-
tion, so as to submit to a careful stethoscopic examination,
some little dulness was discovered at the base of the right
lung posteriorly, and aegophony was also audible there ;  but
as there was no pain on inspiration, no distress of breathing,
and no quickness or sharpness of the pulse indicating exist-
ing inflammation, no treatment was specially directed to it,
but the diuretic mixture was continued as before.   By the
9th of October the aegophony had disappeared, healthy res-
piration was re-established  throughout the chest, and  the
heart's sounds were clear and free  from murmur, so the diu-
retics 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. 0----, aet. 8, who had been seized that morn-
ing by acute pain in the right elbow and the left shoulder, and
on the left side of the chest.  The pain attacked him sud-
denly, 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 pectoralis major.  Skin  hot and perspiring.
Tongue furred.  Bowels costive.   Urine loaded.   Pulse 130,
rather sharp.   Heart's sounds free from murmur.  Perspira-
tion free.   Five grains of  Calomel, followed  by a black 
204     RHEUMATIC INFLAMMATION OF THE HEART.

draught, aided by some saline  medicine, with ten grains of
Nitre, fiften minims of Colchicum Wine, and fifteen minims of
the Vinum Antimoniale, got rid of the pains, within twenty-
four hours, and I saw nothing more  of him  until the 24th,
when I  was again asked to see  him.  He was then com-
plaining of faintness, with palpitation and a  stabbing pain
under the left mamma.   This pain was increased by press-
ure under the ribs on the  left side,  as  also by the effort of
coughing.  There was no  pleuritic  friction nor aegophony,
nor were there any of the fine crepitations 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  perspiration having the
peculiarly sour odour of  rheumatism.   Tongue very furred.
Bowels open.   Urine turbid and  scanty.  Pulse 120, sharp,
irregular, and occasionally intermittent.
  Eight leeches were  at once placed  over the heart,  and
were followed by a large blister; and the following  medi-
cine was prescribed:

     R.   Hydrargyri Chloridi, gr. iij ;
         Opii, gr. _t.  M. ft.  Piluhi 4tu horis sumenda.
         Haustus Salini ex. Ammonia gjss;
         Potassas Nitratis, gr. x;
         Potassae Tartratis 3ss;
         Vini Colchici, fliviij. M. ft. Haustus 4tis horis alternis sumendus.

  25th.—Dozed  during the night, and is much as he  was
yesterday.  The blister rose well, but the friction-sound has
ceased,  the heart's sounds have become feeble, distant, and
muffled, and there is extended  dulness  on percussion in the
cardiac  region.   Evinces  a  tendency  to faint.

              Repetantur pilula? et haustus 4"' horis.
              Ungentum Hydrargyri parti vesicatae.

  26^.—No return of friction-sound.  Further extension of
praecordial  dulness.  Is  very irritable.   In other respects
much as yesterday.   No mercurial action.
            Repetantur medicamenta 4,a quaque hora.
             Rep. emplast. Cantharidis regioni cordis.
        R.    Pulv. Ipecacuanha c. gr. v. hora somni.

   27th.—Slept  fairly.   The blister  rose well,  and to-day
there is considerable  improvement.   Less extended dulness
in the praecordial region.   Friction-sound again audible over 
          CASES ILLUSTRATING THE TREATMENT.       205

the whole extent  of the heart, and the sounds of the heart
much louder.
                 Repetatur pilula sextis Horis.
  Perstet. in usu haustus sed. adde Tr. Scilla), trixl, Tr. Cantharidis, Tttxx.

  During the  next four days  a gradual improvement was
perceptible ; the  heart's sounds became clearer and louder;
the dulness on percussion decreased; the urine increased  in
quantity, 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
averaged  100,  had again risen to 130; the heart's  sounds
were less dear,  and the dulness in the mammary region
had increased.  There was as  yet  no  evidence of mercurial
action,  so the pills  and drafts  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
clearness 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 praecordial dulness had greatly di-
minished.  About this time I had the benefit of a  consulta-
tion 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 clay 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 was no
mercurial fetor, no increased flow of saliva, and no evidence
of full mercurial action.
  By the 11th, the friction sound had disappeared, so the
pills were  omitted.   On the following day, as the  improve-
ment was fully maintained, a draught was  ordered to  be
taken twice a day, containing half a drachm of Nitric Ether, 
206     RHEUMATIC INFLAMMATION OF THE HEART.

eight grains of Nitrate of Potash, and  an ounce of the infu-
sion of Cascarilla; and, as the action of the heart was still
turbulent,  a belladonna plaister was applied to the chest,
and  a pill given every night at bedtime, containing half
a grain of powdered digitalis, 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 his heart's action was regular and
tranquil, and  his appetite good, the medicine was  discon-
tinued.
  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  three  years.   There
has not yet been the slightest recurrence of rheumatic symp-
toms. 
CHAPTER IX.
 ON THE STATISTICS OF HEART  DISEASE IN CONNECTION
                   WITH RHEUMATISM.

  The statistics of heart disease in connection with rheuma-
tism form a subject deserving of attentive  study, not only
on  account of their practical importance to the physician
who is called 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 commonly designated,  " rheumatism of the
heart," is a frequent accompaniment of rheumatic disease, and
forms a fearful addition 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 different forms which it assumes,
and the effect of remedies in warding off its attacks,—"these
are points on which  the number of observations hitherto re-
corded are insufficient to warrant our speaking with certainty.
Dr. Latham, Dr. Taylor, and other inquirers, have done much
towards clearing up existing doubts on some of these matters,
but no one can feel satisfied on a subject of so much import-
ance until their results have been verified by further inves-
tigation.
  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  difference exists between the grounds which
have been chosen as the foundation  of the various calcu-
lations.   Some  persons, for  instance,  in  dividing  febrile
rheumatism into an acute and a sub-acute class, have inclu-
ded many cases in the former,  which others would have 
208
STATISTICS OF HEART DISEASE
surely placed in the latter; and some have arranged in their
sub-acute class many cases which others would have denomi-
nated chronic.  Some have been guided in their classification
solely by the intensity of the  articular inflammation;  some
by  the  severity  of  the febrile paroxysms;  whilst others,
taking  the mixed indication  afforded by the fever and the
articular pain  and inflammation, have  arranged and classi-
fied 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 " sub-acute;" I have therefore
discriminated, in separate tables, between the undoubtedly
acute cases, and those  which, as marked by  less violent
symptoms,  may be regarded  as instances of less  active
disease.1
  Another productive source  of error is the great variation
in the mode in which the different classes of cases have been
grouped  for the  purpose of examination.   Nothing  can be
more 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  therefore  vary according as the conclu-
sions of different observers have  been drawn from acute or
  1  Under the head of Acute Rheumatism, I have classed all cases in whicli
the febrile paroxysm has been -'acute," and accompanied by the profuse acid
perspirations, whieh are eminently characteristic of the acute disease; whilst
under the head of "sub-acute," 1 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 swell ng.  Cases
which have not been attended by a  well-marked febrile movement, even
though accompanied by cedematous fulness about the joint, or by flight effu-
sion 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 experience 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 complications bear a more constant relation to the
amount of febrile movement than to the number and intensity of the articu-
lar inflammations, and that the fever in Rheumatism is a fair exponent of
the  probability of secondary affections, just as Louis has shown it to be in
typhoid  fever, and many oilier acute disorders. 
            IN CONNECTION WITH RHEUMATISM.         209

sub-acute 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 sub-
acute 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  sub-acute cases taken  con-
jointly,  that  I  cannot help thinking they must have been
deduced from a class of cases in which the sub-acute 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 calculations account
for most of the discrepancies which exist between the re-
ports  of various observers.
   The cases  from which my inferences  are drawn, are  379
in  number.  They embrace all the examples of acute  and
sub-acute 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, 1S45, and the 1st of May, 1848, and include 246
examples of the disease in its more acute form, and 133 of a
milder character.  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 per-
 manently deranged to a greater or less extent.   Three tables,
 exhibiting an analysis of these cases are appended  to this
 chapter.1
   Of the  187  cases of heart disease, 130 were examples of
recent mischief,2 as was evidenced, either by the supervention

   1 See pp. 223—227.
   2 It must not be understood, that in all these cases, the heart was pre-
 viously free from disease, neither must it be inferred  that the endocardial
 murmur which  existed, was invariably referable to organic mischief.  These
 are points on which positive information cannot usually be obtained.  I only
 wish to imply, 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 temporary or  permanent exocardial or endocardial murmur.   In seven-
 teen cases the prior existence of heart affection was clearly ascertained, and
 in several others was strongly suspected, and in some, doubtless, the exist-
 ence of a valvular murmur was attributable altogether to functional causes.
 Any attempt, however, to enumerate the cases in which I believe the heart
 to have been previously affected, or the murmur to have arisen from func-
 tional causes, might possibly lead to error, and I have therefore abstained
 from hazarding an  opinion on either of these points.
                      14 
210
STATISTICS OF HEART DISEASE
 of a murmur, after the patient's admission into the hospital,
 or by the existence of a murmur which, though present at
 the date of the  patient's  admission, was found to subside
 towards the close of the  disease, or was coincident with
 praecordial 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 enlarge-
 ment 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 cases of recent, and 4S of old-stand-
 ing cardiac disease, among  379 cases of acute and sub-acute
 rheumatism taken indiscriminately.  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  sub-acute 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  sub-acute cases are
 viewed collectively; and it is  sufficiently formidable in its
 character.  But it assumes a still more serious aspect, vvhen
 the  acute are separated from the sub-acute  cases, and are
 traced in their connection  with the cardiac disease.   Of the
 130 instances of recent cardiac mischief no less than 114 oc-
 curred 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  heart disease among
 246 examples of acute rheumatism.  Now supposing, as be-
 fore, that half the doubtful cases were instances of recent,
 and  half of old-standing cardiac mischief, we find the heart
 affected  with 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 sub-acute  rheumatism alone, a
 remarkable decrease is observed in the proportion of cases in
which  the heart  is affected by pericarditis and other recent
 disease, and an equally striking increase in the proportion of 
IN CONNECTION WITH RHEUMATISM.        211
old-standing  cardiac  affection.   Among the  133  patients
suffering from sub-acute 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 un-
certain ; and in 18 it was  obviously of  old standing.   Divi-
ding the  doubtful 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
sub-acute 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:
Mo. oj Cnsvs of liheiimatisiit.	Total Heart Disease.	Recent Heart Disease	Old-standing Heart Discuses
Acute and Subacute 379	1&7, or 1 in every 2"02	13i0 or 1 in every 2 72	48, or 1 in every 7-89
Subacute . . . 133	42, or 1 in every 3-11	20, or 1 in every 6 65	22, or 1 in every 6-04
Acute .... 246	145, or 1 in every 1 C'.i	119, or 1 in every 206	26, or 1 in every 946
  Thus, it would appear, that 262 in 145, or 1 in every 5.57
of the cases of heart affection met with in acute rheumatism,
are of old  standing; 222 in 42, or 1  in  every 1-9, of those
accompanying the  sub-acute form of the disease ; and 482
in 187, or 1 in every 3-89, of those discovered in acute and
sub-acute rheumatism taken indiscriminately.
  Taking these facts as the foundation of my calculations, I
find that those wdio have  paid the closest attention to the
subject, agree very nearly in fixing upon one half as about
the proportion of cases  in which cardiac affection ordinarily
arises in the course of acute rheumatism.  It occurred, as has
been seen,  in  about this proportion (1192 to 246), amongst
the patients admitted into St. George's Hospital.2  Dr. W.
Budd met with it in about one half, (21 in 43,) of the cases
which fell  under his observation,3 and M. Bouillaud discover-
  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 heait was
previously affected to a greater or less extent in several of the cases in which
recent mischief occurred.
  a This number includes half the cases of uncertain date.
  ' 'Library of Medicine,' vol. v, p. 195. 
212
STATISTICS OF HEART DISEASE
ed it in about the same proportion (65 in 114).1  Dr. Latham
has reported cardiac affection in nearly two thirds (90 in 136)
of his patients,2 but as he makes no mention of old-standing
mischief,  he probably includes  in  his  calculations all pre-
viously 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,3 but as this num-
ber includes both recent and old-standing heart disease, and
is obtained from acute and sub-acute cases taken indiscrimi-
nately, it  becomes necessary to subject  both his numbers 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 sub-acute,' and suppose  nine and a
half, or 1 in every 3-89, of his cases of heart affection to be
of old standing,  we find that 49 represents the number of
cases of acute rheumatism, and  27-5 the number of cases of
recent heart affection, a result which tallies very closely with
that which has been obtained by other observers.  The tri-
flino- differences existing between the results of these various
observations are exhibited in the following table :4
Author's experience 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 recent Heart Affection.	Number of Cases of Acute Rheumatism.	Proportion of OssfS in which recent Ileart affection occurred.
	119 21 65 74 27-5	246 43 114 130 49	1 in every 2-06 1 „ 2-04 1 „ 1-75 1 „ 1-83 1 „ 1-78
	300-5	588	1 „ 1-91
A confirmation of these results is obtained by an examina-
  1 'Traite Clinique des Rheumatism?,' Preface, p. 12.
  a' Clinical Medicine,' vol. i, p. 143.
  s 'Med.-Chir. Trans.,' vol. xxviii. p. 483.
  * 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 endocardial affection, and their quotation therefore would on'y lead to
error.  On much the same grounds, no allusion is marie to Dr. Basham'a
cases. 
IN CONNECTION WITH RHEUMATISM.        213
tion 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,
praecordial 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 rheuma-
tism, and may therefore 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 mis-
chief.   Therefore, although these cases afford data too  im-
perfect 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-
stances, some heart affection 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.
Dr. Corrigan reports it of rare occurrence among  his cases
treated by large doses of opium ;J and among 39 cases which
have come under my care since I first commenced  my pres-
ent plan of treatment, the heart has been implicated in seven
cases only, and in five  of these the affection  commenced
before  I saw the patient.  This number of cases is, doubtless,
insufficient to afford satisfactory evidence on the subject, yet
I cannot help hoping  that  further  experience  will tend to
corroborate these  favorable results, and to show  that the
heart may generally be protected from mischief when the
patient is early subjected to appropriate treatment.
   The frequency of pericarditis is  a point on which many
opposite conclusions have been  arrived at; the difference, I
believe, resulting, as in the former instance, from the variety
of the grounds chosen as  the basis of calculation.   Dr. Mac-
leod1 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 ' Dublin Medical Journal,' vol. xvi.
3 On ' Rheumatism,' p. 154. 
214
STATISTICS OF HEART DISEASE
1 in every 5-7)  of those  afflicted with the different  varie-
ties taken collectively ; Dr. Basham1 reports it in about one
fifth (14 in 66, or one in every 4-7,)  of those suffering from
acute articular rheumatism ; Dr. Latham2 in about one sixth
(22 in  136, or 1 in  every 6-12) ; Dr. Taylor3 in about one
sixth (8  in 49,  or 1  in every 6\t) ; and  I observed  it in
about the same  proportion (39  in  246, or  1 in every 6-3,)
among  the cases  of  acute rheumatism admitted  into  St.
George's Hospital.  Dr. Wm. Budd4 met  with it less fre-
quently 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 what I have termed " sub-acute"
rheumatism, and if so, the  disease probably occurred in
somewhat less than one sixth of his acute cases, (5 in 2S, 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  occurred 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 ;5 in 65  out of 136,
or in  1 out of every 2-09, of  Dr. Latham's cases ;6  in 17-3
  1  ' 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.
  2  ' 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 existed was referable to pericardial or endocardial disease, and it is
therefore presumed that 4 of  these 9 doubtful cases were instances of peri-
carditis.
  a  ' Medico-Chir. Trans.,' vol. xxviii, p. 483.  Dr.  Taylor's numbers are 8
in 75; but he admits that sub-acute cases are included, and about one third
of the entire number have therefore been deducted on that score.
  *  ' Library of Medicine,' vol. v.
  6  My 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 Tabic II, pp. 224-5.
  8  Dr. Latham reports 18 instances 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 affection, wo get 22 cases of pericarditis, and 79 of endocar-
dial mischief.  The number  79, however,  includes cases  of old-standing
cardiac lesions, and on this  score, therefore, we must  deduct 16, or  1  in
every 5-57 cases.   Hence the numbers given above. 
            IN CONNECTION WITH RHEUMATISM.         215

out of 43, or in 1  out of every 2-48  of Dr. Wm.  Budd's
cases;! and in 25-4 out of 49, or in 1 out  of every 1*9, of
Dr. Taylor's cases.2
  A similar uniformity is also apparent  in the  result of an
examination into the relative frequency of recent exocardial
and endocardial affection. Amongst 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 ;3 in Dr. Latham's  cases,3 of 22 to
65, or of 1 to every 2-9; in Dr. Wm. Budd's,3 of 5 to 17-3,
or of 1 to  every 3-4 ;  and in Dr. Taylor's,3 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 frequency  of exo-
cardial and endocardial disease ; and Dr.  Basham has  report-
ed only 7 instances of  endocardial  murmur  amongst his 77
cases of rheumatism, whilst  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 otherwise
than  as 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 result of these investigations are exhibited in the fol-
lowing tables:
  1  Dr. Wm. Budd's numbers are 21 to 43, 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.
  2  Dr. Taylor's numbers are 34 to 75. but as the number 34 includes old-
standing heart disease, and the number 75 is obtained from acute and sub-
acute cases taken collectively, we must deduct 8-6, or 1 in every 3-89 of his
34 cases, as instances of old-st inding disease, and 26, or one in every 2-8 of
his 75 cases as sub-acute. Hence the numbers given above.
  1 See Notes on opposite page. 
216           STATISTICS OF HEART DISEASE
Table I.—Pericarditis.
Author's experience at St. George's Hospital . . Dr. Basham's Cases . . . Dr. Wm Budd's Cases . . Dr. Latham's Cases . . . Dr. Macleod's Cases . . . Dr. Taylor's Cases . . .	Number of Cases of Pericarditis.	'Number of Cases of Acute Rheumatism.	Proportion of Cases in which Pericarditis occurred.
	39 14 5 22 54 8	246 66 43 136 307 49	1 in every 6-3 1 „ 4-7 1 „ 8-6 1 „ 6-12 1 „ 5-7 1 „ 6-1
Total ....	142	847	1 „ 5-97
Table II.—Recent Endocardial Affection.
Author's experience at St. George's Hospital . Dr. Wm. Budd's Cases Dr. Latham's Cases . . Dr. Taylor's Cases . . . Total.....	Number of Cases of recent Endo-cardial affection.	Number of Cases of Acute Rheumatism.	Proportion of Cases in which recent Endocardial affection occurred.
	107 17-3 65 25-4	246 43 136 49	1 in every 2-3 1 „ 2-48 1 „ 2-09 1 „ 1-92
	214-7	474	1 ,, 2.25
Table III.—Relative frequency of recent Exocardial and Endo-
                     cardial Affection.
Author's Experience at St. George's Hospital . . Dr. Wm. Budd's Cases . Dr. Latham's Cases . . Dr. Taylor's Cases . .	Number of Cases of Pericarditis.	Number of Cases of recent Endo-cardial affection	Proportion winch recent Exocardial bears to recent Endo-cardial affection.
	39 5 29 8	107 17-3 65 25-4	1 to every 2 7 1 '• 34 1 « 2 9 1 " 31
	74	214-7	1 " 2-9
  The great excess in the frequency of endocardial affection
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 
IN CONNECTION WITH RHEUMATISM.         217
 functional causes, or by temporary imperfect closure  of the
 mitral  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
 medical officers of the institution, I believe that  somewhat
 less than one-third of all recent cardiac murmurs met with
 among patients  suffering from  acute  rheumatism, will  be
 found to result from pericarditis, and somewhat more than
 one third from endocarditis, whilst the remainder  will  be
 referable to one of the three causes above  specified as con-
 tributing to the  production of valvular murmur.   This at
 least is certain, that the existence of recent  valvular  murmur
 was not accompanied  by praecordial pain,  nor  by any local
 symptoms of inflammation, nor  by any  increase in the gen-
 eral 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 disappeared cannot of course be  ascer-
 tained,  but  it had entirely ceased in  23 before the  patients
 left the Hospital.
  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 observed1 that no less than 114 out of 130  cases of
 recent heart affection 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 ex-
 ceed 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
 strikingly displayed  in the cases observed  by others.   Drs.
 Rilliet and  Barthez2 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
1 See Table I.
*' Traite Clinique et Pratique des Maladies des Enfunts,' \ol. i, p. 210. 
218
STATISTICS OF HEART DISEASE
his children  patients,1 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."2
   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 fre-
quent occurrence of acute rheumatism in persons of tender
years.  But the  Tables  show3 that this will not serve to
clear up  the mystery, for although acute rheumatism is cer-
tainly 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 S2, 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; whilst, above the age of 25, the propor-
tion of cases in which  it occurred  diminishes with even
greater rapidity.   The  more  probable explanation is  that
which I have offered in another Chapter,4 viz., that in youth
the heart is extremely irritable, and therefore 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  conclusions.  The tables I have  given,5 how-
ever, 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 rheumatism
alone in  1 out of every 2-4 men, and in 1  out of every 2-1 wo-
  1 On s Rheumatism,' pp. 156-7.
  8 ' Medico-Chir. Trans.,' vol. xxviii, p. 528.
  3 See Tables appended to this Chapter.
  4 Cap. VI, pp. 124-125.
  * See Table appended to this Chapter, p. 223.  The numbers 71 and 68
include half the cases of uncertain date. 
            IN CONNECTION WITH RHEUMATISM.        219

men.   It would thus appear that heart disease is more com-
mon among women than among men, a circumstance which
accords completely  with the experience of Dr.  Macleod,1
and with the more recent observations of my successor, Dr.
Barclay.2   If  the  extraordinary proneness to heart disease
engendered by youth be  attributable, as I  believe it to be,
to the  greater irritability of the heart at that age, it is prob-
able 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 circumstance, 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 inflamma-
tion is connected with the heart's irritability.
   The form which the  articular  symptoms  assume is obvi-
ously 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 ob-
scure constitutional  peculiarity, most  certain it is that the
fibrous structures are peculiarly apt to suffer in youth, and
the  synovial  membranes in more  advanced  age,  and that
the  occurrence of heart affection 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 fibrous  symptoms
were strongly marked ;3 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 predominating at
one period of the attack, the synovial symptoms at another;
and it has been already stated that no difference exists be-
tween those cases in which the fibrous symptoms  are most
  1 Dr. Macleod reports, '- of the total number of patients laboring under
acute ihenmatism, 137 were males, and 89 females.  Of the former 28, and
of the latter 24, had symptoms of pericarditis ; or of the men, rather less
than 1  in 5, and of the women,  rather more than 1 in 4.   (On ' Rheuma-
tism.' p. 154.)
  a See ' Liincet.' for July 26th, 1851.
  ' On 'Rheumatism,' p. 113.
  * -Medico-Chir. Trans.,' vol. xxviii, p. 522. 
220
STATISTICS OP HEART DISEASE
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 therefore the very cases which are especially prone
to the invasion of pericarditis.   Synovial effusion is  not
necessarily absent, but the fibrous symptoms are  most con-
spicuous.    I  am  not aware that the  same relationship
has been traced between fibrous rheumatism and endocardial
inflammation ;  nor, indeed, can su'ch  a relationship be dis-
covered, if all  endocardial murmurs are to be taken as indi-
cations 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 endo-
cardial affection observed in connection  with acute rheu-
matism, 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
evidence of cardiac inflammation, no less  than 42  occurred
in cases  in  which  fibrous  symptoms were strongly de-
veloped.
  As to the exact period of the attack at  which heart affec-
tion most  commonly arises I am not  able  to speak  with
certainty, nor indeed can I conceive that under any circum-
stances 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 hospital, and therefore before it is possible
to obtain  any accurate information as to the date of the mis-
chief; and if such cases are to be excluded from the calcula-
tion, 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 
IN CONNECTION WITH RHEUMATISM.         221
time the  only local  symptom of rheumatism :* more com-
monly 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  elate  of their admission into  the hospital, gave
evidence  of existing  cardiac inflammation.   On the average,
pericarditis 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     (i
          1       ''       tweuty-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 admis-
sion, 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.
        6  after that date.

   Dr. William Budd reports the occurrence of cardiac affec-
tions as most common between the eighth and the twenty-
seventh day  of the rheumatic attack;2  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.3
  11 have met with three instances, in which the heart was affected 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.
  = ' Library of Medicine,' vol. v, p. 195.
  8 'Medico-Chir. Trans.,' vol. xxviii. 
222
STATISTICS OP HEART DISEASE
   Whether a predisposition to affection of the  heart may
not be engendered by the occurrence of a previous attack of
pericarditis or endocarditis is a question on  which I have
hardly sufficient data to enable me to speak with  confidence.
Theoretically it  is  certain that the occurrence  of cardiac
inflammation must for ever 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 afterwards pecu-
liarly susceptible of morbid  influences; and  it  is equally
certain that, as far as they go, the  ascertained facts corrobo-
rate 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,  there-
fore, the heart may have  been previously implicated.   Of
the 246  cases of acute rheumatism 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 in-
formation,  or from some other cause, I  have made no note
on the subject.  Amongst  the cases which form  the first  of
these classes, there  occurred only 59  examples of heart
complications,  whilst  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
   But although  these facts  exhibit  a lesser tendency  to
heart affection in primary than in subsequent  attacks  of
acute rheumatism, the proportions are altogether  changed
when those cases only are examined in which there is une-
quivocal evidence of true cardiac inflammation.   Thus, of the
39 cases  of pericarditis 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 history of the heart having been  implicated
during the former  invasion  of rheumatism.  Taking the
figures as  they stand, however,  they  exhibit pericarditis
  1 The statistics drawn up by my friend Dr. Barclay, the present Medical
Registrar of St. George's Hospital, from his observation of the cases admit-
ted during the two years ending Dec. 31st, 1850, show that cardiac compli-
cation occurred 18 or 20 per cent, more frequently in subsequent rheum-
atic attacks than in primary ones. 
IN CONNECTION  WITH RHEUMATISM.          223
occurring in 18*1 per cent, of the primary  and in  16-6 only
of the  subsequent attacks, and afford one among many pre-
sumptive proofs that  a large proportion of the endocardial
murmurs which arise  during the course of acute  rheumatism
are not attributable to true inflammation.
                           Table  I.

Abstract of Cases of Acute and Sub-acute 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
  amongst the two Sexes.

Total number of cases, 379.  Of which, 223 occurred in  men, and  156 in
                               women.
Heart affected in 187 instances.  Healthy in 160 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 disctse was of
                               uncertain date.

Of the 130 cases of recent Heart disease, 13 were instances of Pericarditis
                               alone.
      «            «         28 were instances of Endo-peric;irditis.
      '<            "         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, 6 occurred in men, and 7 in  women.
  »   28   "    Endb-pericarditis, 12 occurred in men, and 16 in women.
  «   89   "    Recent Endocardial affection, 48 occuned 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*6
    women.                                             .
Old-standing  Heart disease once in  every * 9 men, and once in every 7-8
    women. 
224
STATISTICS OF HEART DISEASE
	-22g 3 9 K * "'is *S-§ B » K g	w | "3.2	C3	6-s	8 a o 2 •a 3	standing ar and per-Exocardial isease.	5.9
	S-oJa		Pi	73 □	o"3	— a r. H O « «	n a 1*
Under 15 .			3		PS ~	t>^	t> o
	22	12		5	3	_	1
15 to 20 .	82	49	4	11	26	4	4
20 to 25 .	92	49	3	6	26	9	5
25 to 30 .	79	41	1	4	22	9	5
30 to 35 .	40	14	1	1	4	6	2
35 to 40 .	28	12	_	1	4	6	1
40 to 45 .	15	5	1	—	2	2	_
45 to 50 .	14	4	_	—	2	2	_
50 to 55 .	3	—	_	—	—	_	_
55 to 60 .	4	1	-	—	—	1	-
	377	187	3	28	89	39	18
                           Table  II.

Abstract of Cases of Acute Rheumatism, admitted into St. George's HoS'
  pital. from January 1st, 1845, to May  1st, 1848,  showing the number
  which were complicated by Heart disease ; the Age and Sex of the Pa-
  tients in whom  it occurred, the form which it assumed, and the propor-
  tion in which each form occurred amongst the two Sexes.

To<al 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.
          "                 l<        27  were cases of Endo-pencarditis.
          "                 "        75  were cases of Endocardial affec-
                                        tion 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   ,l    Endo-pericarditis, 12 occurred in men, and 15 in women.""
  "   75   "    Recent Endocardial affection, 39 occurred in men, and 36
                   in women.
  "   21   "    Old-standing  disease,  11  occurred in men, and  10 in
                   women.
  "   10   "    uncertain date, 6 occurred  in men, and 4  in women. 
IN CONNECTION WITH RHEUMATISM.          225
Pericarditis then occurred once in every 7-7  men, and once in every  5 2
    women.
Recent Endocardial affection once  in every 24 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.
                            Table  III.

Abstract of Cases  of Sub-acute Rheumatism, admitted into St. George's
  Hospital, between  the 1st of January, 1845, and the 1st of May, 1848,
  showing 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 which each form occurred amongst 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.
Of the 16 cases of recent Heart disease, 1 was a case of Pericarditis alone.
           "              "         1 was a case of Endo-pericarditis.
           "              "14 were cases of Endocardial affec-
                                      tion alone.
                   15 
226
STATISTICS OF  HEART DISEASE.
The 8 cases of uncertain date were all instances of Endocardial disease.
The 1 case of Pericarditis occurred in a man.
 "  1   "    Enrlo-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 6 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 ^ per cent
    among the women.
Recent Endocardial affection occurred once in c\erj 8-3 men, and once in
    every 5-1 women.
Oid-standing  Heart disease occurred once  in every 65 men, and once in
    every 5-1 women.
Under 15 . 15 to 20 . 20 to 25 . 25 to 30 . 30 to 35 . 35 to 40 . 40 to 45 . 45 to 50 . 50 to 55 . 55 to CO .	3 a «- *; cj egg S d 3 * £3 u PS	6 a ■25 a	u a	a W	c 5 *• <	be S.g c * ~ 2 rt U ? 'rj •3 3 X "3	5.S 09 H
	7 24 29 29 18 11 6 5 2 2	3 12 10 8 3 4 1 1	l	• 1 1	1 5 4 2 1 1	3 4 5 2 3 1	1 3 2 1 1
	133	42	l		14	18	8
 
CHAPTER X.
ON  AFFECTIONS OF  THE BRAIN,  INFLAMMATION  OF  THE
    LUNGS AND PLEUP.iE, AND DISORGANIZATION OF  THE
    JOINTS.

  Although inflammation of the membranes  of the heart
is by far the most common complication of acute rheuma-
tism, yet do we sometimes meet with symptoms indicative
of derangement in other organs.  Among these, the most
formidable are  suggestive of disorder of the cerebral struc-
tures.   A patient, for instance, who for a week or ten days
has been  suffering  from acute rheumatism, and has pre-
sented  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 in-
flamed 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.1
  Symptoms such  as these were formerly referred to inflam-
mation  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.2  But pathological  research has  at length dis-
covered 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, although on dissection neither
  1 Some of these cases are characterized from the first by a strange vr&y-
wardness and taciturnity.
  8 Fur an illustration of this fact, consult the record of a ca«e reported by
Mr. Stanley, in the seventh volume of the ' Medico-Chir. Trans.' 
228
AFFECTIONS OF THE BRAIN
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 care; 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
affected.
  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 t  or as expressions of alarm ex-
perienced 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 metastatis of the morbid  action to the cerebral struc-
tures,  in consequence of the subsidence of articular inflam-
mation.  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 afford-
ing the slightest evidence of cerebral mischief.1
  1 In proof of this, I would refer to the cases recorded at pp. 178 and 244 of
this Treatise, as also to the valuable cajcs reported by Dr. Richard Bright,
in his account of spasmodic diseases accompanying affections of the pericar-
dium ; by Dr. George Burrows, in his work on ' Disorders of the Cerebral
Circulation;' by Dr. Lathau, 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,  Rosten, Stanley,  and others, have re-
ported similar symptoms connected with pericarditis, when occurring with-
out any accompanying rheumatism. 
        AS CONSEQUENCES OF ACUTE RHEUMATISM.     229

  The second suggestion  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
crebral 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 con-
nected 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 rela-
tions 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 phrenic1 and pneumo-
gastric2 nerves,  as a consequence of  inflammation of the
pericardium  or endocardium.  By others, however, sympa-
thetic 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.3  But neither of these interpretations appears
to me correct, inasmuch as delirium, convulsions, and coma,
are always rare and exceptional phenomena, even when car-
ditis terminates fatally; not unfrequently arise in cases dis-
tinguished by less than the average severity of their cardiac
symptoms, and in which, therefore, presumption favours 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  when,  therefore, 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  considerable  disturbance of the sensorial functions  is
sometimes associated with  pleurisy and pneumonia when
occurring  in the course of acute rheumatism, is a fact famil-
  ' Dr. R. Bright and M. Bouillaud.
  s Dr. Hope, op. cit.
  8 Dr. Watson's 'Practice of Physic,' ed. 1, vol. 2. p. 276; and Dr. Bur-
rows on ' Disorders of the Cerebral Circulation,' p. 212. 
230
AFFECTIONS OF THE BRAIN
 iar to all practical men, nor can it admit of question, that
 such a complication must interfere materially with the main-
 tenance 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 pleurae, unattended by
 any symptoms, however slight, of cerebral disturbance; and,
 on the other hand, that delirium of a most violent character
 may be,  and is frequently met with, unaccompanied by any
 evidence, either general or physical,  of pulmonary inflam-
 mation.   So, even admitting that carditis and pleuro-pneu-
 monia do  exercise  some influence in producing  cerebral
 disturbance, they can only be regarded  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
 rheumatism, is poisoned by  the presence of morbific matter,
 and the  nutrition of the  brain  interfered with  in  conse-
 quence ;' and although delirium, convulsions, and coma, may
 result in turn from cerebro-spinal inflammation, yet an alter-
 ed condition of the circulating fluid is equally, if not more
 energetic in their production.1   Every one,  for instance,
 knows how certainly  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  influ-
 ence of urea, and how  often it accompanies typhus fever,
 erysipelas, and almost every exanthematous  disorder.   Yet,
 in all these cases, dissection  after death has shown that such
 symptoms  afford not  the slightest ground for the presump-
 tion of cerebral congestion or cerebral inflammation.   The
 brain has  been found paler and drier than  usual, or  of a
 darker colour, 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, the re-
 sult 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 inflammation, every shade  and variety of cerebral
  1 For full and copious illustrations of this important fact, see Dr. Todd's
Lumleian Lectures, for 1850. 
        AS CONSEQUENCES OF ACUTE RHEUMATISM.      231

disturbance, from  slight wandering  or flightiness to violent
maniacal delirium, accompanied  or  unaccompanied by con-
vulsions, 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
occasionally observed in the course of acute  rheumatism.1
For  whilst  we  find acute  rheumatism  attended by  every
species of delirium, and every variety of spasmodic action, we
find almost invariably, 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  some-
times  associated with inflammation in  other organs,  yet
instances  are not wanting  in which  delirium,  by taking
place without the concurrence of any internal inflammation,
asserts its independence of all local action, and ranks itself
amongst 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,2
we meet with  a  similar affection  of the nervous  centres,
unaccompanied  by any evidence  of cerebro-spinal inflamma-
tion.
   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 it3
total absence in  others.  By looking carefully to the circum-
stances under which cerebral symptoms are most apt to arise
in different disorders, we  may  glean  much important in-
formation on the subject.   It is well known that persons of
a  naturally nervous  excitable disposition are  more apt to
experience ill effects  from any interference with their func-
tions, than  are  others of a  more vigorous  and less irritable
temperament.    Moreover,  it has  been  ascertained, that
  1 Dr. Todd has urged this view most closely and forcibly in his admirable
lectures on Delirium and Coma, delivered before the Royal College of Phy-
sicians, but he does not appear to have dwelt  sufficiently on the cause?
which give effect to the operation of the poison in certain cases, and  which
by their absence prevent cerebral disturbance in other?.
 *2 Vide ' Medico-Chir. Transactions,' vol. xxxi, p. 83. 
232
AFFECTIONS OF  THE BRAIN
nervous susceptibility is most fully displayed when the con-
stitution has been damaged by habits of intemperance or by
long-continued ill health.   Not only are persons more prone
under  such circumstances to suffer severely from local  in-
juries, but they are apt to exhibit symptoms of irritation from
causes which in persons of a healthy constitution and less
excitable habit, would hardly give rise to any disturbance.
Thus it is that in old habitual drunkards, whose constitutions
are shattered,  and the polarity of whose nervous centres has
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 ery-
sipelas in persons whose  constitutions have been severely
taxed.   The excess of the   deficiency of the  accustomed
stimulus in the case  of the drunkard ; the  shock and the
loss of blood in the case of the wounded man; and the poison
of the disease in the last instance, proves  sufficient to dis-
turb the relationship subsisting between the blood and the
nervous  centres.  With a brain participating in the general
malnutrition of the  body,—a* heart weak, ill nourished, ill
supplied with  nervous stimulus, and hardly capable of main-
taining a due  circulation,—and a blood  long  vitiated or
impoverished,  it is not difficult to conceive that a slight addi-
tional  cause of irritation or depression may prove sufficient
to disturb the brain's equilibrium, and that an attack of de-
lirium may supervene, whenever, by the presence of some
fresh  morbific matter, by  an increase of the watery part, or
a diminution  in  the coloured corpuscles  of the blood,1 or
indeed by any material alteration in the character of  the cir-
culating fluid, the nutrition of the nervous centres is still fur-
ther interfered 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 symp-
toms.  The shock resulting from the occurrence  of inflam-
mation 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,
1 The natural result of haemorrhage or vcnsesection. 
         AS CONSEQUENCES OF ACUTE RHEUMATISM.     233

irregular, and  intermittent pulse, by which the invasion of
carditis is often accompanied ;  and this in a person already
predisposed by the  vitiated condition of the  blood, would
probably disturb the brain's nutrition sufficiently to give rise
to symptoms of  undue excitement or undue oppression.1
  Thus, then, it  would  appear that, in all  cases  in which
cerebral  disturbance  presents  itself during the  course  of
acute rheumatism, the altered condition of  the  blood is its
primary or proximate  cause; that neither delirium nor coma
are necessarily accompanied by any internal inflammation,
whether of the brain, the heart, or the lungs :  nevertheless
internal inflammation, 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  accompa-
nied 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 prac-
tical  purposes delirium may be  considered as indicative of
some commencing internal complication, 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 facul-
ties, but by symptoms indicative  of spinal irritation.  Just
as delirium may result from the direct action of the rheum-
atic poison on the brain, so convulsions, and other spasmodic
affections, which  are  sometimes met with  in acute rheum-
atism, 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 membranes are  found equally free
from  organic lesion.  Both classes of cases, however, are
usually  distinguished by extensive inflammation of the peri-
cardium or pleurae ; and in the one, as in the other, this local
  1 " 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 c; 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.) 
234
AFFECTIONS OF THE BRAIN
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 inter-
feres 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 irri-
tation of those branches of the phrenic and pneumogastric
nerves which are distributed over the inflamed parts ; for it
has been observed, that in the  cases most remarkable for
choraic or tetanic convulsions, and other symptoms  of spinal
irritation, the inflammation 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 most
abundantly distributed.1
   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 whose articular inflammations are most nume-
rous and  severe,  but in  those who are  pale,  weakly, and
unhealthy; who have been much reduced by  bloodletting,
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,2
experience a relapse after a long and tedious attack of rheum-
atism.   It  is  with  rheumatism, just as  with gout:  the
plethoric  healthy subject, though  undergoing martyrdom
from a severe attack  of gout, escapes  without  the  slightest
disturbance of his sensorial functions, whilst  the thin, the
sallow, and unhealthy, who have long suffered from consti-
tutional derangement, whose  kidneys and liver  are defective
in action,  whose blood is altogether  vitiated, and whose
nervous centres cannot fail to sjmipathise  largely in the gen-
  1 For cases in illustration of these facts, see Dr. R. Blight's essay ' On
Spasmodic Diseases accompanying affection of the Pericardium.'  'Medico-
Chir. Trans,' vol. xxii; Bouillaud's ' Traite des Maladies du Cceur;' Dr.
Burrows, 'On Disorders  of the Cerebral Circulation,' pp. 210-12; and
Dr. Hope, ' On Diseases of the Heart.'
  3 ' Practice of Physic,' cd. i, vol. ii, p. 283. 
        AS CONSEQUENCES OF ACUTE RHEUMATISM.     235

eral disturbance, though presenting far  less  active local
symptoms  of disease,  are  affected  with delirium,  and die
comatose or convulsed.
   Thus, then, as head  symptoms are  invariably connected
with great susceptibility of the nervous centres, are usually
accompanied by active inflammation of some internal organ,
and occur almost always  in persons of a weak excitable
habit, they are  always  indicative of extreme  danger, even
when unattended by cerebral inflammation.   That recovery
does occasionally take place, 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 take place when the
delirium is dependent upon cerebral inflammation, it is im-
possible from experience to  decide, inasmuch as convalescence
itself forms a bar against our only source of positive informa-
tion.  But if, in any case accompanied by symptoms of active
cerebral disturbance, no cardiac or pulmonary disease should
be detected, it would be right, cateris paribus, to speak more
decidedly as to an unfavorable issue, than if the stethoscope
had revealed mischief within the 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, aet. 19,1
was admitted into 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 1843,
and had undergone four similar attacks since that date.  Her
present attack, which had been preceded for three weeks by
languor, chilliness, wandering pains, and general uneasiness,
commenced on the 6th instant with redness and swelling  of
the knees.   On the Sth, 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 follow-
ing day she was decidedly worse ; her countenance was more
1 She was a servant of all wo:k. 
236
AFFECTIONS OF THE BRAIN
anxious, she was complaining of excessive pain in the limbs,
and had experienced several fits of shivering.   On the 11th,
after a restless and sleepless night, during which the inflam-
mation shifted  to  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 was  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, whilst leeches and
mustard poultices were applied to the  chest.  By the 20th
she was greatly relieved;  she  had passed a tolerably good
night; the dulness on percussion in the praecordial  region
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  inflamma-
tion.  Eight leeches were, therefore,  again applied  to the
region  of the heart, while  the mercury was continued as be-
fore.  Nevertheless, an intense  systolic murmur,  audible
both at the'apex and the base  of  the heart, was shortly de-
veloped,  the pulse increased in frequency, her face  again
became flushed, and the countenance extremely anxious, so
that, on the 2-5th,  it  was judged expedient to take eight
ounces more blood from the arm.   Still the mischief con-
tinued, and, as  by the 27th her mouth had become  slight-
ly affected  by  the mercury,  the 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 symptoms pre-
sented themselves.  Her pupils became exceedingly dilated,
her 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 
        AS CONSEQUENCES OF ACUTE RHEUMATISM. *    237

supervened, and was accompanied  on the following day by
violent tetanic spasms, which gave rise, among other actions,
to firm clenching  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,
whilst ice was kept applied to  the head, the delirium con-
tinued incessant up to the 6th of November, when she seemed
thoroughly exhausted and lay motionless on her back, with
her pupils exceedingly dilated, her  mouth open, the tongue
half protruded, dry, and brown, and the pulse rapid, feeble,
irregular, and  intermittent.  Indeed, she  appeared to be
sinking; but she was made to swallow some strong beef tea,
and was given half a drachm of Hoffman's aether, and a quarter
of a grain of  morphia, and under the influence of this medi-
cine, which was  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 delirium had  greatly subsided, and she had
obtained a  few hours' sleep,  and, by the assistance of bark,
which was now administered as well as morphia, the improve-
ment was fully sustained.   On  the  13th, wine was given in
addition  to the medicine, 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 pro-
trude her tongue  when bid to  do so, but she talked inces-
santly  and incoherently, and  oftentimes sang snatches of
various songs 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 mischievous, she remained until
the 24th, when,  after a good  night's rest, she became, for
the first time, decidedly more tranquil.  By the 27th, under
the influence of a nourishing diet, and the continued use of
stimulants  and sedatives,  she  had so far  improved that,
although still excitable and strange  in her manner, she was
allowed to  dress and get up during the day, and from this
time her progress towards recovery was steady.  On the 14th 
238            AFFECTIONS OF THE BRAIN
of December she left the Hospital  to go for a short time to
the Sanatorium at Carshalton.   A slight systolic murmur,
most audible towards the apex of the heart, alone remained
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 mischief, to impoverish her blood, already poor
and deficient in coloured corpuscles, and to exalt the excita-
bility of the  heart, the brain and the system generally!  As
might have been expected, the heart, damaged as it were,
and rendered irritable by the withdrawal of its natural and
necessary stimulus, became unusually susceptible of morbid
influences, and succumbed under the imitation of the rheum-
atic poison.  Pericarditis commenced, and, for the relief of
that inflammation, it was judged expedient to abstract more
blood, and to employ other active  and  depressing remedies.
Their influence on the local action was soon beneficially ex-
erted, and the inflammation was checked.  But  ere long it
broke out in a new quarter.  No sooner was the pericardial
inflammation subdued,  than endocarditis commenced  with
extreme  violence ; with such  severity, indeed, that it was
again deemed necessary to have recourse to leeches and gen-
eral bloodletting, and to recommence the administration of
lowering medicines.  Again the beneficial influence of the
remedies over the course of the cardiac mischief was clearly
manifested, but the brain began to sympathize with the gen-
eral  distress; it  had sustained its functions in spite of 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 in-
capable of performing  its work properly  by  an  attack of
inflammation, both  on its external and internal surface; a
large quantity of the  blood, which, vitiated as it was, had 
AS CONSEQUENCES OF ACUTE RHEUMATISM.     239
been the only source of nourishment to the nervous centres,
had been withdrawn with the view of arresting the rheum-
atism, and checking the progress of the cardiac inflamma-
tion, and medicines of a most depressing character had been
freely administered for the same  purpose.   No wonder that,
under such  a combination of circumstances,  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  adminis-
tered freely, and the constant application of ice to the head,
failed utterly in affording relief  to these symptoms, as  did
also calomel in full and  repeated doses.  After a time, how-
ever, it  became obvious that the symptoms were  referable
to " excitement without power,"1 and morphia was there-
fore again resorted to in combination with  sulphuric aether.
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 in-
fluences, and  required its  failing energies to be roused, as
well as its abnormal irritability subdued  and tranquillized,
and as day by day this  was more fully effected by means of
nourishment,  stimulants,  and sedatives, the brain showed
how great was the benefit it derived.  It gradually reassumed
more and more of its healthy functions in proportion as the
pulse betokened a return of power.
  "Without entering largely into  the detail of cases which in
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 illus-
trate some of the facts already mentioned.  And first, in
regard to the rarest of all forms of head affection occurring
in connection with rheumatism,  that, namely, in which  the
brain or its membranes are  inflamed.
  A man who had long suffered from rheumatism was ad-
mitted 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
  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 mnnia. 
240            AFFECTIONS OF THE BRAIN
much smaller and flaccid, and, coincidently with the subsi-
dence of the swelling, he complained of pain in the head,
became paralysed 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 hemisphere,  and
there was considerable effusion  into the  ventricles.1  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, unequivocal pus was  found smeared  over the hemis-
pheres.2   So, again, in a case reported by Dr. Fife, of New-
castle-upon-Tyne.3  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  continued 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 membranes  of the brain
covered with lymph and pus,  the  vascularity of the brain
enormously  increased, and the lateral ventricals 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
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  subsi-
dence of articular inflammation.
  Inflammation of the brain, however,  as already stated, is
a rare accompaniment of acute rheumatism; the head symp-
toms 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 out-
lines of which are given in a former chapter,4 afford an illus-
tration of this important fact, as do also many cases which
others  have put on record.   Thus, one of the  children of
Christ's Hospital, who was suffering from acute rheumatism,
was attacked, on the third day  of his illness, with delirium
1 Dr. Seymour's Clinical Lecture.  ' Medical Gazette,' vol. xix.
2 Quoted in Dr. Todd's Lumleian Lectures, for 1850.
3 ' Medical Gazette,' vol. xxix, p. 703.
4 Cap. VII, pp. 167, 168. 
        A3 CONSEQUENCES OF ACUTE RHEUMATISM.     241

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  was  an instance of the severest in-
flammation of the brain.   The boy pointed to his fore-
head 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  discovered the slightest  morbid
appearance.   The  disease of the heart was not confined
to its  investing membrane.   It was the most intense in-
flammation pervading the pericardium  and the  muscular
structure.1  So, again, Dr.  Richard  Bright reports of a
young man whom he  attended in the year 1836.  He had
been  suffering from acute rheumatism six days, when spas-
modic 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
unfortunate sufferer under restraint.   He  died  at  the expi-
ration of three weeks,  and  on dissection  the  brain was
found  perfectly healthy, and the pericardium and endocar-
dium presented unequivocal signs of recent active  inflam-
mation.2  Dr. Watson has placed  several  cases on  record,
in one of which  the endocardium  alone was the  seat of
inflammation.3  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.4   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 restless-
ness and  delirium, and upon  examination of the  body the
pericardium was found covered with a network  of recent
  1 The particulars of this case are detailed by Mr. Stanley, in vol. vii, of
the ' Medico-Chir. Trans.'
  2 ' Medico-Chir. Trans.,' vol. xxii.
  3 ' Medical Gazette,' vol. xvi, p. 93.
  4 ' Practice of Physic,' ed. 1, vol. ii, p. 276.
16 
242
AFFECTIONS OF THE BRAIN
lymph, whilst " upon  the  anterior surface of the left ven-
tricle of the heart, there was a white spot about a quarter
of an inch in diameter, which appeared to  be formed by
concrete  pus."1   The  latter  reports that a young  woman,
after  suffering  for  some days  from rheumatic fever, was
seized with delirium, and in  a  few hours afterwards had a
convulsive fit, succeeded by coma and death ;  yet the closest
examination of the parts after  death, whilst it exposed ex-
tensive inflammation of the pericardium, could not  detect a
trace  of inflammation of the brain, which, together with its
membranes, were unusually pale.2
  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 consti-
tutional derangement is so great as to occasion disturbance
of the nervous centres, the rheumatic  poison is present in
large quantity, and usually gives rise to cardiac inflammation.
But, though  comparatively rare, they do sometimes occur.
Dr. Todd had made mention of some, and  I  have myself
seen three in which slight wandering or delirium has 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.  My friend Mr. Pyle, of  Oxford Terrace,  Hyde
Park, has favoured me  with the particulars of another case.
A gentleman, whilst labouring under  symptoms of acute
articular rheumatism,  became  affected  by tetanic  spasms,
opisthotonos, and convulsions.  Delirium of a violent char-
acter  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 pleurae, 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 inflammation,  but cases are  occasionally met with,
1 ' On Disorders of the Cerebral Circulation,' p. 188.
1 Lumleian Lectures, published in the ' Lancet' for 1853. 
AS CONSEQUENCES OF ACUTE RHEUMATISM.
243
in which the effects of cerebro-spinal  irritation are mani-
fested by furious delirium and violent spasmodic action, termi-
nating only with  the patient's life, and in which, therefore,
it is possible, by a post-mortem examination, to obtain pos-
itive evidence  as  to the absence  of carditis, and of every
other form of internal inflammation.  Such a case occurred
in St.  George's Hospital, in  the  year  1850.  It has  been
already referred to in a previous chapter ;J but the inferences
deducible from it are of such importance, that I do not hes-
itate to give it in detail.
  Ann Amess, aet. 21, a 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,  accom-
panied 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
swelling 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 in the 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 anaemic  origin.  In short, no evidence
could be obtained of mischief within the chest.  The  perspi-
ration 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 even-
ing with  increased violence and obstinacy.   They did not
now subside towards morning: the dawn of day showed her
restless, tremulous, and excited, and, with the  approach of
evening,  she became still more excited and delirious.  Mor-
phia had been given in vain;  and laudanum, in full doses,
was now resorted to, with the view of tranquillizing the nerv-
ous centres;  but the head symptoms rapidly increased  in
severity; she became violently delirious, so that she  had  to
be held in bed; she  then lapsed into a state of coma, and
1 Cap. VII, p. 177. 
244
AFFECTIONS OF THE BRAIN
expired on the morning of the 3d of February.  When coma
supervened, Mr.  Hammerton, the  resident medical officer,
bled her to six ounces, and the blood was neither buffed nor
cupped.
  Dissection after  death showed the  brain  and its mem-
branes rather drier than usual,  but  without any other re-
markable  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 exhibit-
ing no trace of recent inflammation.  The pericardium  con-
tained about two ounces of serum ;  the heart  and its  valves
were perfectly healthy,1 its right cavities contained  fibrinous
coagula.  The peritoneal cavity contained a small quantity
of turbid serum.  The liver and pancreas were healthy; the
spleen soft and flabby; the kidneys slightly  congested, espe-
cially 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 col-
league, Mr. Keate, who sent her into the hospital, had for
some time been  sitting up  at night, engaged in nursing an
invalid.  He told me, when she was first admitted, that she
was much exhausted by her labors; and the loud anaemic mur-
mur which was heard throughout the attack, and the crop of
sudamina which very shortly appeared, attested the correct-
ness of his judgment.   Then  came the delirium,  indicative
of the irritability consequent on that  exhaustion ; and,  in
direct  corroboration of the evidence afforded by the symp-
toms, the blood drawn from the arm was  neither burred 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 inflam-
mation could be found, and the fact became apparent that
the symptoms  observed during life were due to the morbid
  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.     245

blood acting upon nervous centres, rendered more than usu-
ally susceptible of irritation by the exhaustion to which the
patient had been subjected.   The delirium  was obviously
referable neither to congestion nor to inflammation, but to
excitement without  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 ad-
mission ; convulsive contraction of the fingers, after a time,
supervened ;  and, subsequently, tetanic spasms  commenced
in various parts of the body.
  When first seen  by M. Bouillaud  his countenance  was
most anxious, his eyes were fixed, and the pupils dilated.  His
intellect was unobscured, but his voice was rendered trem-
bling by the constant sobs called forth by the severity of the
cramps  in his  limbs.  No part of his body was free from
pain.  His mouth  could hardly be opened,  so firmly and
spasmodically was it closed; his fingers, arms and fore-arms,
toes and feet, wTere 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 suffer-
ing,  was a constant sense of suffocation.  In spite of gene-
ral and local  bloodletting, together with warm-baths, and
the internal administration of opium, the attacks of spasms
recurred continually; the symptoms of trismus became more
urgent and distressing; the least attempt to swallow very
greatly aggravating his  suffering ; and he  died, exhausted,
on the tenth day from the first appearance of spasms in the
fingers.
   The spasms had been regarded as symptomatic of inflam-
mation of the spinal cord, but dissection revealed an inject-
ed condition of the pericardium, and within its cavity about
two  ounces of pure creamy greenish pus, whilst in its brain
and its meninges, a  slight congestion only was observed, and
in the spinal cord and its membranes no unusual appearance
beyond a small circumscribed  spot of softening at the supe-
rior enlargement of the cord.1

      1 'Bouillaud's Traite des Maladies du Cceur,' torn, i, p. 333. 
246
AFFECTIONS OF THE BRAIN
  Death, however, is not a necessary consequence of cere-
bro-spinal irritation, and, therefore,  however alarming the
symptoms, our  prognosis  should be  extremely guarded.  I
have already narrated the particulars of one case,1 which fell
under  my own observation, in which recovery took place
under circumstances 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,  aet. 19, was attacked, on the 12th of Janua-
ry, with feverishness, accompanied, on the following day, by
redness and swelling of various joints, and by other charac-
teristic symptoms of acute rheumatism.   She manifested no
untoward symptom  until the  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 con-
stant jactitation, so that it was never still for  an instant;
the right leg was similarly affected, but to a less extent; at
times,  however, this  state became aggravated  into one of
general convulsions of a tetatic 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 treat-
ment  throughout consisted  of bleeding, general and local
repeated blistering,  and mercurialization;" and  as soon as
the system was brought fully under the  influence of mercu-
ry,  the severe  symptoms were materially alleviated.  On
the 13th of February 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
ascertained is their connection or  non-connection with any
internal local inflammation.  If we  are unable to discover
1 Page 235 of this Treatise.
8 ' Medical Gazette,' new series, vol. x, p. 457. 
         AS CONSEQUENCES OF ACUTE RHEUMATISM.     247

any signs of cardiac or  pulmonary inflammation, and  from
the absence of symptoms of cerebral or spinal inflamma-
tion, we are led  to  regard the disturbance of the  nervous
centres as functional only, then,  as in delirium  tremens,
or erysipelas, the invasion of  head symptoms should  be
a signal to us  to support  and tranquillize our patient by
the administration of nourishment, stimulants, and opiates.
In no case is opium,  in  combination with diffusable stimu-
lants, of greater service than in this atonic form of delirium ;
and  in none is venaesection  more prejudicial.   If,  on the
other hand, we  detect active cardiac or pulmonary mischief,
or from  the presence of symptoms  of inflammation of the
brain,  such as excessive  heat  of head, injection of the  eye,
intolerance of  light, and vomiting occurring coincidently
with hardness  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  symptoms in each particular instance.  In
Buch cases  our efforts should be directed to the speedy sub-
jugation of those actions going on within either the chest or
the cranium, which  experience has proved to be intimately
connected with the occurrence  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 noto-
rious that venaesection and other depletory measures have  a
tendency to reduce the  proportion of red corpuscles in the
blood,1 and to produce a condition favorable to the develop-

  1 See Note. p. 78 of  this  Treatise. MM. Becquerel and Rodier after
analysing their  experiments, as to the effect produced by venaesection in
the blood sumup by stating: '" In short, the effect of venaesection is to cause
a great diminution of the  corpuscles."  (Simon's ' Chemistry,' vol. l, p. 260.")
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,
apparently 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 analysed.  The blood drawn on
the first bleeding, on  the 6th of April, contained in 1000 parts—
                      142-85 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—
                       113-54 Corpuscles,
                         4-72 Fibrin,
                         810-89 Water. 
248
AFFECTIONS OF THE BRAIN
ment of delirium and convulsions, we should be exceedingly
cautious in having recourse to their employment, lest by
still further impoverishing  the blood, and impairing the
powers of the constitution, we seriously endanger our pa-
tient's recovery.  In cases marked by evident symptoms of
cerebro-spinal  inflammation,  it  may  be necessary to  have
recourse to blood-letting; but if in ordinary cases of rheum-
atic carditis the expediency of  venaesection is questionable,
much  more so is it in those where the nervous centres are
irritable, and are suffering from  the  effects of malnutrition,
arising from an altered condition and an irregular supply of
blood.  Even local depletion, though sometimes expedient
in such  cases  for the  relief of active local inflammation,
should be seldom practised to any great extent.  We should
rather endeavour to support our patient, whilst aiming at the
relief of the more urgent symptoms, by means  of blisters,
mercurials,  diuretics, and opium.   We  should economise
strength by administering opium in doses sufficient to re-
lieve the pain and tranquillize the excited nervous centres,
and at the same time support the fading powers of the sys-
tem by means of a  nourishing  and  stimulating diet.   We
thus may check the tendency to death, and give our reme-
dies time to play their part.  By degrees as the cardiac inflam-
mation is subdued, the  fluid effused into  the  pericardial
sac is  reabsorbed, and the heart gradually acquires greater
freedom  of  action.   Coincidently with this improvement in
the centre  of  circulation a  corresponding improvement is
effected in  the  blood  by the  gradual elimination of the
rheumatic poison, and thus  the irritability of the nervous
centres is lessened,  and  the symptoms gradually subside.
One exception  only there is  to the full, though cautious ex-
hibition of opium.  I refer to those instances 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
  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.     249

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 acute rheum-
atism, and which 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 struc-
ture, sometimes invading  all parts simultaneously, producing
dyspnoea, suffocation, and death.  " Such forms of pulmonary
inflammation are portentous ingredients in the clinical history
of acute rheumatism, and give a fearful interest to it,"1 and
they are the more formidable from the fact that they generally
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
pneumonia, 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 the cardiac affections.2 Hence
its appearance is fraught  with unusual danger.  For, as the
primary cause  of inflammation is diffused throughout the
blood, and consequently comes in contact with every part of
the pulmonary tissue, inflammatory action is no sooner excited
than it sp reads 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  oc-
curred," 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 arrived.  In the four  instances of bronchitis,
the affection was no mere  catarrh,  but an  inflammation
largely diffused through both lungs, producing deep oppres-
sion  and dyspnoea.   Of  the  two pleurisies, one was single
and the other double.  The single pleurisy produced a large
effusion 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.
a See note at p. 132 of this Treatise. 
250     INFLAMMATION OF THE LUNGS AND PLEURA

  My experience at St. George's Hospital tallies very closely
with that of Dr. Latham, at St. Bartholomew's.   He  has
reported some form of pulmonary affection in 24 out of  136
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 examples were noted: among those accompanied by
pericarditis alone, 7 : and among those accompanied by endo-
pericarditis, 19 occurred.   In other wrords, some  pulmonary
affection of an inflammatory nature was observed,—
In 7 out of 1271 or in 1 out of every 18'1 cases uncomplicated bj recent car-
                                 diac mischief.
 " 8   "   801  " 1    "     10-0 cases complicated by recent endo-
                                 cardial affection alone.
 " 7   "   12  " 1    "      1*7 cases complicated by  exocardial
                                 inflammation alone.
 " 19   "   27  " 1    ''      1-4 cases complicated by endo-pericar-
                                 ditis.

  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 pneu-
monia, and twice pleuro-pneumonia.
  In  the third, it was  partly bronchitis, partly pneumonia
in four instances, pleurisy in one instance, and partly pneu-
monia, partly pleurisy in  the remaining two.
  In the fourth, it was bronchitis in one instance, pneumo-
nia 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-pneumonia1 were present.2
  Formidable, however, as these members are, the propor-
tion of cases in which pulmonary inflammation has arisen in
acute rheumatism, has been even greater in the experience
of others.  Thus Dr. John Taylor,  of Huddersfield, reports
that  of  11  cases of rheumatic pericarditis,  pleurisy  was

  1 The numbers 127 and 80 each include 5, or half of the cases in which
the date of the mischief was uncertain.
  3 For illustrations of this fact see Cap. VIII, pp. 167-176 of this Treatise. 
        AS A CONSEQUENCE OF ACUTE RHEUMATISM.    251

found in 5, and pneumonia in 5.   In 4 of the latter there
was pleurisy as well.1
  The physical symptoms of rheumatic inflammation of the
lungs and pleura, are such  as are  met  with in ordinary
pneumonia and  pleurisy,  and  therefore need  not be more
particularly dwelt upon, nor is there anything beyond the
severity  and  intractability of the disease, which calls for
especial notice.  But in the treatment of such  cases it must
ever be  borne in mind that the  symptoms arise from no
common local  cause of irritation.  The inflammation  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, we
must employ means calculated to promote the neutralization
and elimination of the rheumatic virus, which is at once the
source and maintenance of the mischief.   And  experience
has proved what theory most justly leads us to anticipate,
namely,  that  blisters  and derivatives  are  more efficient
than general venaesection, and that, although local depletion
and full mercurial action may be needed for  the relief  of
excessive  local  action,  yet that  no cure can be effected
without due regard to the neutralization of the poison, and
the promotion of the various excretions by which its elimi-
nation 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  whilst  employing blisters and the
other remedies mentioned, the serious nature of the local
mischief must not for a moment be lost sight of, and accord-
ing 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 pericar-
ditis, 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 if  under these circumstances unnecessary
'Medico-Chir. Trans.,' vol. xxviii, p. 514, 
252     INFLAMMATION OF THE LUNGS AND PLEURA

depression be  induced by over activity in the treatment, a
healthy lymph-effusing  inflammation may  take on an un-
healthy pus generating character.
  The following  cases may serve to illustrate the violence
of, and the extreme danger attendant upon, inflammation of
the pulmonary structures when occurring in  the course of
acute rheumatism.
  Fred. Ford,  aged 32, came under  my care at St. George's
Hospital,  on  the  16th of November, 1850, suffering from
acute rheumatism of four days' duration, principally affect-
ing 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 anx-
iety.  Auscultation revealed a  loud  systolic mitral murmur,
as also pleuritic friction and  a?gophany at the seat of pain.
He was a thin  and sickly person, a working tailor by trade,
and three times a  day had been taking, by my orders, a ni-
tre  draught, with fifteen minims of Colchicum wine, ten
drops of Laudanum, and  a drachm of the Potassio-Tartrate
of Soda.  Directly he began to  exhibit  symptoms  of pul-
monary and cardiac inflammation, twelve leeches were ap-
plied 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 Tartarizcd 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 leech 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, mod-
ified perhaps in its course, until the whole  of the  left side
of the  chest  was dull on percussion, and aegophony was
audible  only in the supra scapular region.  Nor did the pleu-
ritic inflammation alone proceed unchecked.   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 third of the
right lung.  Five days more passed away, during which a blis-
ter was again applied, and yet there  was no material amend-
ment 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. 
        AS A CONSEQUENCE OF ACUTE RHEUMATISM.    253

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 became gradu-
ally less embarrassed, and  the  case  proceeded favorably to
its  termination.   Blisters were repeatedly  applied to the
chest, and  diuietics  were freely given; and  on the 23d of
January,  1851,  the  breathing  was fairly re-established
throughout the chest, and my patient had got rid of his  pres-
ent distress, at the expense  of  a damaged  mitral valve, and
an universally (?) adherent pleura.
  Cases, however, not  unfrequently occur, in which, either
from  the extent and  intensity of  the  pulmonary inflam-
mation,  from the  fearful mischief  in  other organs which
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 16 fatal cases of which I have given abstracts in
a previous Chapter,  no fewer than  9 were accompanied by
extensive and acute pulmonary inflammation.1  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 before her  admission into the
hospital.   She was attacked during the catamenial  period by
pains all over her, and shiverings, with occasional  heats and
sweatings.  She was also sick.  The pain then " fell on her
chest," with  much cough and thick  expectoration.  A  week
afterwards 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
  1 See Cap. VII, of this Treatise.  Subjoined is an account of the pulmo-
nary inflammation in the several cases.
   Case i. Pneumonia on both sides of the chest, going on to partial hep-
              atization of the lungs.
     "  ii. Pneumonia affecting both lungs, and double pleuiisy.
     " in. 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. Bionchitis affecting both lungs.
     " xn. Single pleurisy.
     " xv. Pneumonia of bolh lungs going on to the production of grey
             hepatization.  Single pleurisy. 
254    INFLAMMATION OF THE LUNGS AND PLEURAE

sternum, increased  on inspiration.   " On the 6th of March
she was attacked by a severe rigor, the first of a long series
of shivering fits, which afterwards 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 was  greatly distended by a tolerably firm coagu-
lum: its valvular surface was beset by numerous warty vege-
tations, 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  haemorrhage had followed in
the lungs, which exhibited many instances of the  circum-
scribed 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 num-
bers on the auricular  surface of the tricuspid valve, some of
them even projecting round into  the cavity of the ventricle.
The other viscera were generally healthy."1
   Another case, in which the pulmonary symptoms assumed
an equally grave aspect, fell under my observation in St.
George's Hospital  in the year  1S45.  Frances Webster,
aged  18, a thin delicate girl, whose father was a martyr to
rheumatism, was admitted into the  hospital on the 14th of
March, under the care of Dr.  Wilson.  At the age of 15,
whilst recovering from scarlatina, she had been attacked by
acute rheumatism,  and had ever  since been subject, at short
intervals, to wandering pains in the limbs, unattended, how-
ever, 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 rheumatism, which showed themselves
by inflammation of several of the  larger joints.2  On ad-
  1 See the Report, by Dr. Wilson, in the ' Lancet'  for November 16.
1844.
  a " 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 evidently attacked some days before the invasion of the joints. 
        AS A CONSEQUENCE OF ACUTE RHEUMATISM.     255

mission, coincidently with redness and swelling of the joints,
there existed endocardial and exocardial inflammation.  There
was  extreme irregularity of the  pulse, with extended  dul-
ness on percussion in the praecordial region.  The heart's
sounds were distant and muffled, 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 bellows-murmur was
distinctly audible.   Small bleedings  were  resorted to, a
blister was applied to the chest, and saline  medicines, with
antimony, were administered,  whilst the  system was being
brought  under the influence  of  mercury.  By degrees  the
physical signs  gave evidence of the salutary  effect of the
treatment employed, for the heart's sounds became clearer
and  less distant,  the dulness  in  the praecordial region less
extended, and  the pulse  steadier.   At the  same time  the
articular swellings subsided, and everything seemed to prom-
ise a favorable issue.  But on the 12th day after admission,
the articular inflammation recommenced, and with it a catch-
ing  pain  on the  right  side of the chest, accompanied by
pleuritic friction  and aegophony, announcing the  superven-
tion 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 oppressed, her powers  of life  were
manifestly failing, and her back began to slough. Still, how-
ever, she  lingered on, and  even  survived  an attack of peri-
tonitis which supervened a few days afterwards. But on the
27th 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 wras expected, a
heart not greatly enlarged, but presenting a pericardium
almost  universally adherent,  by means of  recently effused
lymph;  a mitral valve fringed with  beads and festoons of
recent lymph  and fibrin ;  a copious effusion 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.1
  1 For further particulars respecting the  autopsy of this case, see the
'Abstract,' at p. 168, of this Treatise,  as also the 'Post-mortem Book,'
for 1845, preserved in the Museum of St. George's Hospital. 
256    INFLAMMATION OF THE LUNGS AND PLEURA

  How full of painful interest are such cases! how pregnant
with hints for our guidance and instruction !  No particular
organ or set of organs were 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 mem-
brane of the  abdomen, the synovial membrane of the joints,
the ligaments of 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 effects
of any local agency! No impartial inquirer can fail to admit
the importance 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 ia
for  any length of time stationary.   Generally speaking, the
liability to this occurrence varies  in inverse proportion to
the number of articulations affected, but there is always just
grounds  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 acute lymph-effusing inflammation
of the joints, and,  in  some few instances, to suppuration,
that I am convinced of the necessity for the greatest vigi-
lance 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 inflamma-
tion 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 better enforced
than by citing the particulars of one or two cases in which,
during life, there has been every token of threatening artic-
ular disorganization, or every evidence after death of exten-
sive 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, 1050.   She had been suffering  nearly two 
        AS A CONSEQUENCE OF ACUTE RHEUMATISM.     257

weeks from acute rheumatism, principally affecting the ri<mt
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 in-
flamed as over, and the pain was aggravated by the slightest
motion.   Still I hoped to conquer the disease by the agency
of me.lie-lne addressed to  the relief of rheumatism,  but as,
at the end of a fortnight, she had shown no signs of  amend-
ment, and mischief appeared imminent, I judged  it expedient
to put some leeches on the joint, and to follow their appli-
cation 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
ensure perfect rest, her arm was placed on a splint,  and the
wrist was blistered as  before.  This completed what the first
local applications had effectually begun; the pain sub-sided,
and there remained only thickening of the parts about the
joint, and some  effusion, probably of thickening synovial
fluid, within the capsule.   This was, ei'ter a time, removed by
■absorption, under the influence  of  the compound  Iodine
lotion, and she was discharged on the 16th of November, but
little stiffness of the joints  remaining.
   80 also in the case of Ann ConoDy, 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 admis-
sion, 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  salhu-s,  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 crepi-
tation could at last be distinctly felt in the affected joints.
In spite  of blisters and mustard poultices which were repeat-
edly applied, of colchicum, which was administered inter-
                   17 
258
DISORGANIZATION OF THE JOINTS
 nally, 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 Novem-
 ber, when s/te had very little motion in the thumb, and her finger
 was anchylosed in a  bent position.
   Some cases, however, do not issue so favorably; the pa-
 tient sinks either from the irritation of the articular inflam-
 mation, or from the concurrence  of  some  serious internal
 complication.  In such cases there has been found every stage
 of acute articular  inflammation, from  simple  congestion to
 extreme capillary injection of the  affected parts, with effu-
 sion of lymph and pas. In the case of the young girl already
 referred to (p. 243) as having been complicated by active
 delirium,  " each  knee-joint  contained  rather more than
 a drachm of turbid glutinous serum,  which was alkaline,
 highly albuminous, containing many oity 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 seer* three times as  large as those  containing
 granular matter and nuclei.
   " In the upper part of the'  cavity of each joint, a thickish
 mass of fibrin an inr/> and a half broad, and about the same length,
 was 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 upper part of each
joint was seen to be intensely red, and highly vascular, and to pre-
 sent the most striking contrast to the white shining cartilage
 in which no vessels could  be  traced, and which was not al-
 tered in appearance.
   " One elbow joint was  opened,  and it contained  a clear.
 glutinous, synovial  fluid, apparently without any cells in it."1
   In some instances inflammation has produced even more
 disastrous consequences, having gone on rapidly to suppura-
 tion and  complete disorganization of the joint.   A case in
 which ulceration of the cartilages took place,  has been re-
 corded by my colleague, Mr. Caeaar Hawkins, in the ' Lan-
 cet,' for August 23d,  1851 ; and others are to be found in the
 various medical journals. Within my own observation, five in-
 stances have occurred, of three of which an abstract has been
  1 St. George's Hospital Post-mortem Book for 1850, preserved in the Mu-
seum of the Hospital. 
        AS A CONSEQUENCE OF ACUTE RHEUMATISM.     259

already given.1   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 quantitv of thick
puriform fluid.   The left knee-joint  contained a larger quan-
tity of synovia than natural, and the synovial  membrane of
this joint was slightly increased in vascularity."2
   As  then very serious lesions may arise from rheumatic
articular inflammation, even when the  greatest caution is
observed, and as such lesions are more likely to occur when
the local symptoms are  neglected, it behoves us to  do all in
our power for their relief,  and to  watch carefully for the
earliest indications of commencing mischief.  From the first*
as already stated,  much  comfort may be aiibrdecl by the ap-
plication of warm  or tepid fomentations, and repeated experi-
ments  have convinced  me that none  prove  so efficient as
the alkaline and sedative solution, of which I have elsewhere
given the formula.3  When this is fairly and fully employed
from the first,  evaporation  being  prevented  by means of
gutta percha, or Markwick's epithem, articular  mischief will
rarely if ever happen.  But in such  matters it is not prudent
to run the slightest risk, and when inflammation attaches itself
with more than  usual obstinacy to  any particular  joint,
leeches or a blister should be at once applied, and repeated,
if necessary,  whilst 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 See abstract of  Cases iv, vii, and xvi, recoidcd in Cap. VII.  In Case
xiii, a large number of pus globules were discovered by the microscope, but
as the fluid contained in the joints appeared to be thickened synovia, con-
tiiininif pus globules, rather than a purely purulent or sero-purulent fluid, it
is probable, that suppuration was only just commencing at the lime of the
patient's death.
 a For a detailed account of  this case, with the dissection after death, see
St. George's Hospital Post-mortem Book for 1845, p. 281.
 * Paws 101. 
CHAPTER XL
                  ON  RHEUMATIC GOUT.

  Closely  allied to  rheumatism, yet partaking largely of
the nature of gout, is that obstinate, painful, and distressing
malady, which is known under the title of Rheumatic Gout.
Whether viewed in relation to the amount of present suffer-
ing it inflicts, or to the  permanent  injury and distortion it
entails, it ranks  among the most  formidable of this class of
disorders.  Its  symptoms are not only  temporarily 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 often causing thickening and
permanent enlargement; in rarely involving the heart or its
membranes; and in sometimes  producing desquamation of
the skin.   In all  these  particulars  it strikingly 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 as  frequently as men; in in-
vading several  joints  simultaneously  ;  and  in  being  very
migratory in its local symptoms.   In  all these points its
rheumatic nature is strongly marked.  It maintains, indeed,
as its  name implies,  a place intermediate between the two
disorders; it is  identical with neither,  yet presents some
characteristics of both, and  is, therefore, well described by
the compound title of  Rheumatic  Gout,  which expresses its
hybrid nature.1
  1 This disease has been described by Dr. Macleod, under the title of
" Capsular Rheumatism." and by Dr. Todd, under that of ■' Chronic Rheum-
atism of the Joints."  Both appellations, however, appear  to me objec-
tionable, inasmuch as they ignore the existence of many gouty symp'oms, 
RHEUMATIC GOUT.
261
  In its acute, and apparently most terrible form, it may be
reatlily confounded with acute rheumatism ; but when care-
fully examined, its history, symptoms, progress, and termi-
nations, all serve  to illustrate  its  distinctive  character.—
Referable  without  doubt to some  constitutional peculiarity
closely connected with perverted assimilation, it selects, as
its victims, cither the weakly and unhealthy, in whom  the
natural  excretions  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 attacks
the girl just arriving at puberty, in whom  the  uterine func-
tions 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 follows  a miscar-
riage', or a  difficult  and  protracted labour, more especially
when the labour has been accompanied by flooding; it  is a
frequent attendant upon renal disease, and 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  age nor sex  affords immunity
from its invasion; but most commonly it shows itself from
the age of thirty-five onwards;  and  its earliest  attacks  are
usually seen in girls  whose uterine functions  arc suspended
or ill-performed.1
which Dr. Macleod very properly regards as c> aracteiistic cf the disease,
and which Dr. Todd can only explain away by stating that they are pathog-
nomonic of another disorder.  I shall presently  give the reasons which
have induced me to consider the symptoms  alluded to. as holding an inter-
mediate place between rheumatism and gout, and  as neither wholly refera-
ble  as Dr. Macleod considers, to rheumatism, nor wholly attributable, as
Dr. Todd would have it, to gout.
  1 In almost every instance which his fallen under my notice of its occur-
rence in very earlv life, it has been eitln-r hereditary, or else connected with
disordered uterine function.  Within the  last year, I have had two girls
under my care, at St.  George's  Hospital, of the  respective ages of fifteen
and seventeen, whose joints were frightfully distorted by the disease.  In
the former, the menses has 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
Jif ill health.  The first of these patients, at my earnest  desire, went  for
four months to Bath, and returned much benefited hy her residence there.
Dr. Haygarth's experience also led him to connect its appearance in women
with irregularity of the catamenia, for he remarks. (Clinical Medicine,' p.
183,) that -'out of thirty-three women in whom he observed  it, three only
were afflicted  with it  during the period of regular menstruation, and of
these, one had suffered twelve abortions.-' 
262                RHEUMATIC GOUT.
   Its attack, when acute, may be ushered in by considerable
fever, together with pain and aching of the joints, and, after
a time, some redness may supervene, just as in a paroxysm
of ordinary rheumatism.  But more generally there is little
external 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 perspira-
tion 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 com-
plexion and the  conjunctivas, the yellowness of the fur on
the tongue, and the paleness of the alvine evacuations.
   The form and the situation of the articular swellings pre-
sent 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 articula-
tions are attacked,  the character of the swelling is peculiar
and  diagnostic.   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,  rather
than into the surrounding structures.   In the knee-joint this
peculiarity is strikingly manifest.  Whilst there is little, if
any, effusion into the  surrounding tissues, the synovial mem-
brane, full and  distended, may be  seen projecting at  those
parts where  the adjacent  structures  offer least  resistance,
and, if the two hands be placed one on either side  of the
joint, fluctuation may be  made  perceptible  to the touch.
The adjoining  bursas, too,  and the sheaths of the tendons,
are more frequently implicated, and 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,  al-
though 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 sub-
acute or chronic form, inflammatory action will often persist
for months, producing permanent and irreparable  mischief.
Nor  are the differences  confined  to the points already spe-
cified ;  they  are strikingly marked  in the  nature  of  its 
COMPLICATIONS WHICH ATTEND IT.
263
complications.  It is unaccompanied by the frightful  heart
disease which proves so fatal in acute rheumatism, but it
has for its attendants, inflammations of the eye, the pleurae,
and the brain.
  Sometimes, however, the diagnosis between acute rheum-
atism and 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 affecting the larger in preference to the smaller
joints, in  wliich, 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 inflammation, though less urgent in its charac-
ter, has been extremely obstinate in its continuance, and has
lost its distinctive migratory character; the skin has been
no longer bathed in perspiration ; 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 commenced,  in  the first instance, as
a sequel of acute rheumatism.  In two instances of this sort
the  patients, after a time, came again  under my notice,
suffering  from  well-marked rheumatic gout, which, in this
second attack, had not been preceded by  symptoms of rheum-
atic fever.
   When  the disease assumes a chronic form,  it  admits of
much more ready diagnosis.  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 coloured, and of low specific
gravity.   The  patient's  chief complaint  is  of  languor and
loss of appetite, with occasional chilliness,  and pain and stiff- 
264
RHEUMATIC GOUT.
ness in the joints, which soon become swollen from effusioH
into their synovial cavities.  The principal evidence of mischief
is furnished by the sallowness of his complexion, the yellow-
ness of the conjunctivas, the constipation of the bowels, the
pale  and unhealthy character  of  the dejections, the low
specific gravity of the urine, the feebleness of the pulse, and
the slow yet steady enlargement of the joints—an enlarge-
ment which in many cases is unaccompanied by any percep-
tible  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 bursas 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 distinctive feature.  The irritation of a poison  which
has been attracted  to the joint for a sufficient length of time
to cause 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 cartihiges
with  wdiich the structures  in question are intimately  con-
nected, are  generally 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 them-
selves become  irregularly enlarged by expansion of their
osseous tissue, and the deposit of osseous matter around the
joint.1  A material alteration is thus  produced in the form,
  1 ':The great distinction of this process from ordinary inflammation, con-
sists in this, that in the chronic rheumatic affection." .-.s Dr. Colics has well
remaiked, " two very opposite processes are to be found gobii on at, the same
time, viz., absorption of the old bone and its cartilage of incrustation, with
deposition of new bony matter, whilst in  the ordinary inflammation theie
would be simply a gradual enlargement of the bone.  It is worthy of remark.
that in the malignant disease of the joints, and in strumous affections of
them, both connected with constitutional  taint, there is the se.mo tendency 
     NATURE OF THE CHANGES INDUCED IN THE JOINTS. 265

and oftentimes in the direction of the joint.  The fingers, for
instance, which are very prone to be  affected, arc° drawn
towards the ulnar or outer side of the hand, and take a per-
manently oblique direction ; whilst the enlarged, and partly
dislocated extremities of the bones,  more especially of the
metacarpal bones, project in every variety of form, and con-
stitute the  " nodosities" which have  been described by Dr.
Haygarth, in his ' Clinical History of Disease.'1  Strange  as
it may seem, these  changes in the form and direction 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 extraor-
dinary symmetry^ of arrangement is  exhibited in the local
manifestations of the disease.
   In connection with this enlargement of the joints,  there
seldom exists any deposit  resembling  the  chalky deposit  of
gout.  The first series of changes are usually confined to an
alteration in the nutrition of the  parts affected, which causes
them to lose their  natural brilliancy and  elasticity, and  to
become thickened,  opaque, and  altered in colour.   After a
longer period of exposure  to the irritation of the rheumatic
element, a further alteration  of  structure takes place;  pro-
cesses of thickened synovial membrane are seen dipping down
into depressions existing  around the head and neck of bones ;"
or a  dense  ligamentous  substance,  resulting probably from
some peculiar alteration  in the synovial membrane, is  seen
interposed between the  articulating  surfaces ? or small ir-
regularly-shaped  cartilaginous  bodies arc  found  existing,
either loose within  the joint, or attached  to  it bv pedicles
formed of thickened  synovial membrane;4 or the opposed
to the formation of exuberant osseous growths around the joints, while the
articular textures within arc suffering destruction and decay."  (Todd on
'Rheumatism,' p. 1G9.)
  'I quite agree with Professor Rokitansky. ('Pathological Anatomy,' p.
173.) that  the changes in these cases are not due to simple rheumatic
ar hritis. but have more or less of a gouty o ijjin.
  2 See Mr. Adams's articles in the,- Cyclopedia of Anatomy and Physiology.'
as also the Reports of Messrs. Adams. Canton, and Prescott Hewett, in the
'Transactions of the Pathological Society of London.'
  3 A case illustrative of this change in the synovial membrane will bo found
in Sir Benjamin's Brodie's 'Observations on Diseases of the Joints' p. 11.
Specimens illustrative of this morbid appearance may be seen in the Museum
of Sr. George's Hospital.
  4 For a full description of the minute structure of these bodies, see a Paper
by Mr. Ralney, quoted in the 'Transactions of the  Pathologijal Society of 
266
RHEUMATIC  GOUT.
surfaces of the bones denuded by chronic wasting of the car-
tilages, and rendered smooth by attrition  upon each other,
are found white, glistening, and  ivory-like in appearance.1
  But in some cases, which differ materially from true gout,
and present all the characteristics of the  hybrid disorder I
am describing, there exists a deposit more or less extensive
of a white pulverulent 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 structure, and fills the cancelli
of the subjacent bone.2  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,3 is identical, or nearly  identical in  composition with
the deposit which exists in gout, and that  it occurs in those
cases only of« rheumatic  gout  which  approximate  most
closely to genuine gout, is  susceptible of  easy proof;  but I
cannot therefore admit the conclusion, that the existence of
such  deposit is  of itself sufficient to mark such  cases as
examples of true gout.  For  it usually takes  place in thin
spare persons of temperate habits, whose  symptoms have in
many respects resembled rheumatism more nearly than gout;
it differs  greatly in  its form  and situation from that which
is met with in well-marked gout; it often occurs in persons
who, in their younger days, have been martyrs to rheuma-
Lowlon ' for 18-18-9, p. 110.  Some beautiful preparations exhibiting these
bodies in situ, may be fceen in the Museum of St. George's Hospital.
  1 This condition has been described and delineated by Cruveilhier, under
the t'tle of'.Usmc des Cartilages.'  Cases in point, are recorded in Sir B.
Brodie's work  'On  the Joints,' ed 4, p. 322, as also in the 'Trans, of the
Pathological Society.   Specimens are preserved in  the Museum of St.
George's Hospital.
  2 See Report  by Dr. Hand field Jones, in the 'Pathological Transactions'
for 1848-9.
  3 This was distinctly proved in some cases of Dr. Chambers, as also in a
case of Mr.  Stanley's, of St. Bartholomew's Hospital, (reported by Sir C.
Seudamore, in his work on ' Rheumatism.' p. 351.) in which the deposit con-
si-ted 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, sec Simon's ' Chemistry,' vol. ii, p. 477. 
 MODE OP DETERMINING THE NATURE OF THE DISEASE. 267

tism ; and sometimes co-exists with those structural changes
in the joints, wdiich everybody admits to be dependent upon
rheumatism.   Thus, amongst  cases  differing in no  respect
from each other in their external character, there are found,
in some, extensive structural alterations in the joints, but no
traces, however slight,  of  earthly deposit; in others, the
same altered condition of the articulations is  accompanied
by an evident, though  scanty and  irregular earthly deposit;
whilst 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 predict with tolerable accuracy whether any deposit will
or will not be discovered in the joints after death;  but in
many instances the symptoms are  of such an hybrid charac-
acter, as  to preclude the possibility of arriving at  any cer-
tain conclusion.  Even dissection fails in some instances to
disclose any strongly-marked difference between those cases
which are, and those which are  not, accompanied by such
deposit; for  occasionally one joint maybe found  smeared
over with earthy matter, whilst 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
disposition, or for  a rheumatic tendency to arise in a gouty
habit, I have come to  the conclusion that  the  disease is in
part rheumatic, in part gouty in its nature, and that the dif-
ference in the  results  observed after  death, arises from the
greater prevalence of the gouty element during the time the
first-named joint was affected, and of the rheumatic element
during the affection of the latter.
  When the superficial joints are attacked by this disease,
the  symptoms above described will generally enable us to
recognize its true character.  But all joints are liable to its
invasion, and when those which  are  deep-seated suffer, the
diagnosis  is  much more difficult and uncertain.  This  is
more particularly the  case  when the  hip-joint is the part
implicated.   Local pain, or  a sense of stiffness unaccompa-
nied by heat, or by any material  constitutional disturbance,
is usually the first symptom to attract  attention, and oft'en-
times considerable alteration in the joint will have occurred
before steps are  taken for  its relief.   As  the disease pro-
gresses, the pain  becomes  more  constant and severe, and
is felt more  acutely when the weight is thrown on  to the 
268
RHEUMATIC  GOUT.
affected joint.   After a time, other symptoms arise, depend-
ent on the changes progressing within  the joint.  For,
in the hip,  as  in the other joints, the disease  is attended
by  the deposit  of  ossific matter around the head of the
bone,  with  gradual wasting  of  the  cartilages, and ebur-
nation of the  opposed  articulating surfaces.  And, as the
bony  deposits  take place  irregularly,  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 the absorption 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 appear-
ance.   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 ; whilst, from the  difficulty or
impossibility of  rotating the leg,  circumduction  of the limb
is rendered necessary.
  The symptoms just  described, point unequivocally  to
mischief in the  hip, yet, as  this  rheumatic affection is usu-
ally limited to  the one hip,  and rarely extends to other
articulations,1 the unwary might be led to attribute the mis-
chief  to some  other and a  purely local cause.  But care-
ful inquiry into  the history  of the case will seldom fail  to
unveil the mystery.  The patient  will generally be found
to have suffered from rheumatism at some former period; or
to have recently experienced pain in some of his other joints;
or, possibly, to  have had slight temporary swelling in the
knee, or  in one of his toes or knuckles ;  and thus a clue to
the nature of the disease will at once be obtained, and may
be  safely acted on.  Indeed, such a discovery  is of great
practical importance, inasmuch as it often  leads to the em-
ployment of remedies addressed to the relief of constitutional
derangement, when the  treatment might otherwise  have
been purely local.
  The treatment required  in the acute form  of rheumatic
gout,  differs  little  from  that of rheumatism,  except that
from  the character  of the persons attacked, it need seldom
be  actively antiphlogistic, and from the inflammation of the
1 See' Cyeloparlia of Anatomy and Physiology ' article " IIi;»." 
             TREATMENT OF THE ACUTE FORM.          269

joints being more  stationary, and the danger of structural
disorganization greater, there is more necessity for the appli-
cation of leeches, blisters, and fomentations to the inflamed
parts.  General venassection is rarely, if ever, needed in this
form of disease, even when  most acute, and opium, as  was
pointed out by Dr. Corrigan,1 is of far less importance than
in genuine rheumatism.  Indeed, alkalies, colchicum, small
doses of antimony,  and alterative doses of blue pill or calo-
mel, with an occasional purgative, topical applications to the
joints, and strict attention to diet, arc usually sufficient for
the relief of its more active symptoms.
  When speaking of the treatment of acute rheumatism, I
entered 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 will be gained by a reiteration of cau-
tions which hold good as  well in  this form of disease, as
in that we were then considering.   Colchicum and alkalies
are as necessary here as in genuine  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 adminis-
tration  of remedies, the greatest care should be taken not
to depress the system unnecessarily ; if, in genuine rheuma-
atism, this  caution is needful, much  more so is it here,
where the  disease  occurs in the weakly or cachectic, and
exhibits a remarkable tendency to pass into a chronic form.
Whether mercury and purgatives, or colchicum be employed,
rare must  be taken so to  administer  the  medicines  as to
remedy defective secretion, eliminate the  poison, and re-
store 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  inilammation  of
the  joints,  and even if he  escape articular disorganization,
nothing, in my experience, so greatly tends to endanger re-
covery, nothing assists so much in perpetuating the  rheum-
atic state, as over-active and depressing treatment.

  1 "There is one  form of acute rheumatism,"_ he  says, "in which the
opiate treatment will cause disappointment;" it is that in which '' whf-n
rheumatism  does appear, it is not  genuine rheumatism, but a  combi-
nation of gout with iheumatisra."   ('Dublin Medical Journal,' vol. xvi,
p. 2C7.) 
270
RHEUMATIC GOUT.
  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 condi-
tion 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 coloured and offensive, or else  pale  and
deficient in healthy bile.   In  some  such 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 ; 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, followed 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,1 and antimony  given,  whilst a full action is
thus maintained, the intensity of the febrile action is speedily
mitigated, and the patient is  brought into a state to benefit
by  other remedies.    Cases  wliich prove  intractable  by
alkalies, colchicum,  and  mercury,  yield readily  to their
influence after the febrile action has been subdued by the
means just  alluded to.2   In  most  instances the early  and
assiduous employment  of appropriate fomentations  will pre-
vent the occurrence of articular mischief, and  obviate  the
necessity for more active local remedies.  If, directly inflam-
mation 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
topical application will  be needed.   But the neglect  of  this
simple and rational precaution exposes the structures to the
  1 Not more than from §iv to gvj of blood should be taken in these cases.
  a Dr. Graves, in alluding to this class of cases, remarks, " Cases of rheum-
atic 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.) 
APPROPRIATE  REMEDIES.
271
mischievous effect 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
disease1, 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 followed by speedy abatement of pain and  swelling,
and  even  in  sub-acute and  lingering cases,  or at  a later
period of the attack, will still afford considerable benefit.
But  it is usually necessary to employ counter-irritation in
order to effect a complete removal of the mischief.  When
much effusion or thickening 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  effusion, blisters  maintain
the good effects produced, and remove the evil consequent
on the action wliich 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 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 symp-
toms 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 inflammation.  Whilst perfect freedom  from mo-
tion is thus ensured, 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 rheumatic gout,
as in many cases of genuine  rheumatism,  are frequently of
essential service ; I mean vapour and  hot air baths, and warm
baths of various descriptions.   They  promote perspiration to
an extraordinary degree, and unload the system without great-
ly depressing it.   Hence in those instances which are marked 
272
RHEUMATIC GOUT.
by harshness and dryness of the skin, they prove of inestimable
value.  One species of bath, wliich from the nature of the
case it is  difficult to  make use of  during a paroxysm of
acute  rheumatism, may be employed in this complaint with
great advantage, namely, the warm bath rendered alkaline by
the addition of two or three  ounces of the carbonate  of soda.
The value of this auxiliary in combating the disease, has been
ably pointed out by Dr. Wright of Birmingham ;l and within
my own experience many  cases which have long  resisted
ordinary treatment, have  yielded  readily  as  soon  as  this
alkaline bathing has been commenced.  It certainly possesses
virtues wliich 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.  Kepeated on
alternate days, a bath of 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 restoration of health.
  The foregoing  observations have  been confined  to the
treatment of the disease as it  is met  with in the more
vigorous, and in those who have heretofore 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 stimulus 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  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 speci-
fied afford but little and but temporary abatement of suffering.
In them the whole conditions of  the case are altered.  The
skin is usually cool, if not harsh and unperspiring ; the tongue
but slightly coated ; the pulse weak and irritable ; the urine
abundant, pale  coloured, and of  low  specific gravity, often
containing a trace of albumen ; all of which symptoms point
most significantly to the presence of a  small quantity only
1 Lectures published in the 'Medical Times,'for June IS 17. 
      AS IT OCCURS IN THE WEAKLY AND CACHECTIC.   273

of the poison, and to a defective condition of the excretory
organs as the principle cause of its accumulation in the sys-
tem.  Hence medicines which prove serviceable to the one
class of patients, are found useless to the other whose excre-
tory 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 kid-
neys and liver, we are  unable permanently to affect the
character of the secretions, we  must endeavour to improve
the tone of the system generally, and so to render the excre-
tory organs  more efficient 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 potas-
sium, and liquor potassas, when aided by change of scene and
air, active exercise and judicious bathing, proves one of the
most efficient means of rousing the dormant energies of the
system,  and restoring the power of the  excretory  organs.1
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 weeks, 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 improvement  in the  health,  there has been  a cor-
responding 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.
1 The formula I usually employ is—
Tincturaa Cinchona?, 3jss) or else Liquoris Potassae, Ttixv;
Liquoris Potassae, lUxv;         Potassii Iodidi, gr. iij;
Potassii Iodidi, gr. iij ;           Extracti Sarzae, 3j ;
Decocti Sarzae, % iij, ter in die,     Decocti Cinchona;, 3xj, ter in die.
                  18 
274
RHEUMATIC GOUT.
   Sometimes, however, the stomach is so much deranged,
 that it will not tolerate bark or other tonics; and, under such
 circumstances, an emetic forms an admirable precursor of
 other remedies, and  does much towards preparing the way
 for their administration.  On several occasions I have known
 the appetite return,  the digestive function improve, and the
 excretory organs reassume  their due activity, under the in-
 fluence of medicines which, prior to the action of an emetic,
 had proved quite inoperative.
   In most  of these cases  the liver is very  sluggish in its
 action, and the secretions of the bowels are unhealthy; con-
 sequently, during the administration of these remedies, it is
 necessary to employ some gentle laxative.  Calomel, and in-
 deed  every form of mercury, is  apt to prove exceedingly
 depressing; so instead of having recourse to  its administra-
 tion,  it  often becomes advisable  to  prescribe  a  morning
 draught, consisting  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 administer from half a drachm to a drachm of the extract
 three times a day, in combination with alkalies and the infu-
 sion of gentian, adding, when necessary, a little  tincture of
 rhubarb, or half an ounce of the compound decoction of aloes.
  In recent cases,  which are not accompanied  by much
 hepatic derangement, and in which there is want of tone in
 the system, the  greatest benefit is often derived from the
 cautious use of the shower-bath. Indeed, among the younger
 sufferers from this complaint, I know of no single remedy so
 generally efficacious.  Even when, under ordinary circum-
 stances, the patients lack sufficient vigour to withstand its
 shock, it may often be made available for their relief by
 ordering it to be taken whilst they are standing in a warm
 bath of the temperature of 98°, in which they have been
 previously immersed, with the view of stimulating the cu-
 taneous 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 vapour-bath, cautiously
 employed, than from any other external remedy.  To them
the shower-bath is too depressing: it chills and exhausts them,
 and is not followed by the  salutary glow of reaction which
 ensues after its  employment in the younger or less weakly.
 The warm bath, too, if frequently employed, proves equally 
TREATMENT OF THE CHRONIC FORM.
275
depressing, and often fails in giving rise to that flow of per-
spiration which  is found so efficacious as a  relief to  the
sluggishly-acting liver and kidneys : and, although a sulphu-
retted and  alkaline bath,1 or a simple  alkaline bath, if cau-
tiously employed and steadily persisted in, is often efficacious,
it yet proves slow in producing its salutary effects.  But the
vapour-bath, if not too frequently had recourse to, and per-
sisted in only for a  short  time, unloads without greatly
depressing  the  system.  It rapidly produces  copious per-
spiration, and the skin, thus stimulated to vicarious action,
throws off  a  vast quantity of excrementitious matter which
for some time has been slowly accumulating in the blood.
Considerable relief is thus obtained during the interval which
must elapse  before  the medicine can have  fairly done  its
work in invigorating the system,  and restoring the functions
of the various excretory organs.
   In effecting this salutary  change in the constitution, the
iodide of potassium  is particularly serviceable, and I there-
fore seldom fail to recommend its administration in two or
three grain doses.  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 exhi-
bition 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 guaia-
cum 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  dis-
turbance, quina is an admirable and effective substitute, and
may be administered either with or without sulphate of mag-
nesia, according to the exigencies of the case.   The addition
of fifteen or twenty minims of the dilute sulphuric acid of
the ' Pharmacopoeia '  is often of the greatest  service.   By
such variations in the combination of these remedies, relief
  1 The subjoined formula, by Messrs. Planche and Boullay, makes an ex-
cellent artificial Sulphuretted Bath :—
           Sulphuret of Soda or Potash, gnj ;
           Carbonate of Soda. 3ij ;
           Muriate of Soda, 3ij;
           Sulphate of Soda, % ;
           Distilled Water, Oj. Mix, and then add the mixture to 20
gallons of Water, at the temperture of 98° Fahrenheit.
• 
276                 RHEUMATIC  GOUT.

may almost  always be  obtained, even when it  has been
sought  in vain  from the exhibition  of colchicum, calomel,
and the whole class of medicines which prove so beneficial
in acute cases, occurring in persons  of a more healthy con-
stitution.
   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 combina-
tion 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, combined with  three drachms
of the  oil, has often proved, in  my  hands, a  most valuable
remedy; and in no single instance in which its administra-
tion has  appeared advisable, has the  slightest ill  effect
resulted 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 sluggish, or the alvine evacuations
deficient in quantity, the patient becomes heated, and the
articular symptoms 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
   Whilst thus  attending to the condition of the internal
organs,  and  promoting a healthy change in the assimilating
functions, the practitioner should not  neglect  to provide in
other ways  for the relief of the local symptoms and the
elimination  of the poison which  has been already generated.
He should call to his aid such external applications  as have
  1 The following are pills I frequently employ, and have found exceedingly
useful:—
Ipecacuanhas, gr.jss;
Saponis Castiliensis, gr. iv j
Pil. Rhei C, gr. iij ;
Ext. Aloes Aquosi, gr. i. M. ft.
  Pilulae ij, quarum sumat j,
  vel ij, hora somni.
Or, Ipecacuanhas, gr. jss 5
   Pil ula? Hydrarg. gr. j ;
   Pilulaa Rhei C, gr. iij ;
  Ext. Colchici Acet, gr. ij. M. ft.
    Pilu!a> duae, quarum capiat j,
    vel ij, hora somni.
« 
            TREATMENT OF THE CHRONIC FORM.         277

the power of lulling pain and maintaining warmth in the
affected parts, of exciting free  cutaneous action, and of pro-
moting 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 which treats of the more acute forms of the
disease.  If the joints  be wrapt up in Markwick's epithem,
or in  a flannel  saturated  by  the  aforesaid solution,  and
covered by a coating of gutta percha,  a genial glow and
perspiration  is 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
uneasiness is felt.  By this simple expedient much unneces-
sary 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  calcu-
lated to invigorate the constitution and  restore a healthy
state of assimilation.
   Amongst 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 rheuma-
tism are well aware of  this important fact, and rarely fail to
maintain,  by means of the flesh-brush, that unobstructed
condition of the  skin's pores which  is essential to free cuta-
neous  transpiration, and so to  the  elimination of the mor-
bific 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 bursa?, or the sheaths of
tendons, which resists all  ordinary  attempts to produce its
absorption.  Sometimes the knee-joint is the refractory part,
and if so, repeated blistering, followed by the application of
mercurial ointment to the blistered  surface,1  proves the most
  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 
278
RHEUMATIC  GOUT.
effectual method of stimulating the absorbents, and getting
rid of the obnoxious secretion.   But it frequently happens
that some of the small joints of the fingers, to which blis-
ters 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 recourse to some
other mode of relief.  In such cases, liniments and embroca-
tions have been recommended,  and,  in  some instances,
considerable  benefit has  been derived from those of a tere-
binthinate and oleaginous nature.  But generally,  such  ap-
plications possess little virtue beyond that which attaches
to them in consequence of the  friction  wliich  accompanies
their use ; and far  greater benefit will  usually be  obtained
from the  local application of iodine to the affected joints,
than from the whole  of this class of remedies.  With per-
sons whose skin is irritable,  the  simple tincture of iodine
may be employed ; but in most cases a  stronger application
may be used consisting of a drachm of iodine, and a drachm
and a half of iodide of potassium, dissolved  in an  ounce of
rectified spirit.  Another very useful, though not an agreea-
ble application, is cod-liver oil, containing iodine in  solution.
Whichever is  adopted should  be painted freely over the
affected parts by means  of a camel's  hair brush, and  its
application should  be continued  daily, and twice  a  day if
the skin will bear  it, until the effused fluid is entirely ab-
sorbed.   It will generally produce smarting and desquama-
tion of the cuticle, which is not sufficient to contra-indicate
its use, but should the irritation be excessive, and accompa-
nied, as it sometimes is, by vesication, its application should
be suspended, and may be replaced by the iodide of potassium
ointment, which is  far less irritating in its nature.   In some
instances, however, greater benefit is derived from the appli-
cation of  the  emplast. ammoniaci c. hydrargyro, than from
the ointment just referred to.
  One subject, and that by no means an unimportant one,
still remains to be noticed.  The imperfect condition of the
assimilating function requires  the  observance of the strictest
rules of diet.   The food should be  wholesome and nutritious,
evidence to prove that, locally applied, it produces a primary and distinct
effect, totally independent of its action on the general economy."  (Dr.
Graves's ' Clinical Mediciue,' ed. 2; vol. i, p. 490.) 
GENERAL RULES IN REGARD TO DIET.        279
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 very small quantity,
as tending to promote acetous fermentation; and  for the
same reason salads and pickles should be  avoided, as  also
beer, sugar, and'all  sweets.   More specific injunctions can
hardly be laid down axiomatically ; but, as a general rule, I
would assert with Lord Bacon, " it is a safer conclusion to
say, ' this  agreeth not well with me, therefore I will not
continue it;'—than this, ' I find no offence 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 coffee, 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 sufferer from rheum-
atism 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 bever-
age, 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 the 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 persons 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.
  Above all things, it is needful for the sufferer from rheum-
atic gout to take  exercise freely and regularly—exercise
  1 Bacon's 'Wisdom of the Antients.'   "Essay on the regimen of
Health.'' 
280
RHEUMATIC  GOUT.
suited to his strength and condition, but always sufficiently
active and sustained to produce a free perspiration.  Nothing
tends more directly to the perfect oxigination 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 vicissi-
tudes, 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.
  Sometimes, however,  after  several  attacks, the disease,
acting 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 caution on the part of the patient, the stomach
performs its functions 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 sys-
tem,  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 Conti-
nent,  as if for the relief of the disease in question.  When
everything else fails, they not unfrequently afford extraordi-
nary  and permanent relief.  Whatever the  modus operandi
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, irri-
table  and anxious, repairs to  the springs, unable to sleep,
and,  troubled with  dyspepsia, connected with  a  sluggish
condition 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 effi-
ciently, that it  becomes unnecessary to have  recourse to 
         CURATIVE EFFECTS OF THERMAL SPRINGS.      281

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 symptoms, which arise,  as I have shown, from a
vitiated condition of the circulating fluid.   There is no fresh
accession of pain or inflammation, no recurrence of synovial
effusion,  no increase of thickening about the joints.  On the
contrary, the enlargement gradually subsides; and by the
assistance  of the  water  applied in 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
regularly at home, and  diligent  use  may be  made of baths
containing the same  constituents in solution, but the effect
is far different from that observed during a residence at the
springs.  The vast importance of the total change of scene
and air consequent  on  a visit to the English or continental
watering-places, can hardly be over-estimated : a new stimu-
lus 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 influence, as to the medicinal action of
the waters.
   The only  question, therefore, which arises  in  each  par-
ticular instance, is as to the place best calculated to promote
the well-being of the patient.   In this country  the waters
of Bath  and  Buxton, abroad  those of Aix-la-Chapelle,
Wiesbaden, and Baden-Baden;  Teplitz, and Bareges,1 are
among the most celebrated and efficient; but of course, the
physician's selection must be determined by the result of his
inquiries into the history  of each case.  The springs of Aix-
la-Chapelle and Bareges belong to  the class of sulphurous
waters;  and, being  more stimulant  than  the  other waters
  1 The temperature and composition of most of these waters are given in
the table appended to this Chapter.  See p. 286. 
282
RHEUMATIC GOUT.
alluded to, are sometimes of service in old-standing atonic
cases, even when other waters have failed.  Those of Bath,
Wiesbaden, Baden-Baden, and Teplitz, contain in solution a
small quantity of iron, and hence are especially useful when-
ever there is a deficiency of red globules in the blood; whilst
those of Buxton are most beneficial in cases  marked by the
existence of wandering  pains without the concurrence of
inflammatory  action,  or of chronic  thickening about  the
joints,—in cases  therefore which require alterative waters
rather than those of a more stimulating nature.  To persons
of a robust habit, afflicted with simple rheumatism, the tepid
springs  of Buxton are  extremely beneficial, whilst  those of
the other places mentioned are equally serviceable, in a dif-
ferent class of cases, when administered with due regard to
the condition of the patient.  But observation has convinced
me, that he  who is tormented by  rheumatic gout in  a
chronic form 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  ex-
tremely intractable, whatever the means adopted for their
relief.   They are characterized by the unusual pallor of the
patient, the dryness if not harshness of his  skin, the pale-
ness 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 which
it is difficult to conceive  that a cure can be permanent.   In
the obstinate cases just alluded to, this defective  condition of
the urinary secretion is even more prominent, and is too
often connected with permanent alteration of the structure
of the kidneys,  which increases with the progress of the
disease  until complete degeneration of their secreting appa-
ratus 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 the  microscope, scales of
glandular epithelium will be seen, containing an undue pro-
portion of oil globules  and granular matter, and  here  and
there will sometimes be observed a fibrinous  cast of an urin-
iferous  tube, and some  small aggregations of amorphous 
SUPERVENTION OF HEAD SYMPTOMS.       283
granular matter and half-broken epithelium.  Moreover, if
the urine be concentrated by evaporation—sometimes indeed
without previous concentration—a slight coagulum of albu-
men will  be formed under the influence of heat and nitric
acid.  After death, the  cause of this abnormal condition is
apparent:  the  kidneys are found atrophied, 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
bowels, and by regulating the  amount  and nature of the
food ; by relieving the diseased organs of part of their work;
by  stimulating  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  towards warding off the final catastrophe.
Though we cannot effect a  cure of the disease, we may ren-
der our patient's  sufferings endurable, and enable him to
pass the remainder of his  life in comparative  comfort to
himself and family.
  I have  hitherto made only slight  allusion to  the various
complications which  render this complaint peculiarly for-
midable, 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 frequent  occurrence under  other  circumstances, and
do not demand  any specific treatment.  Inflammation  of the
brain has been  met with, though rarely, in connection with
the disease, and has almost invariably occurred coincidently
with the subsidence or  sudden retrocessson 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, with headache, incoherence, strabis-
mus, paralysis,  and symptoms of pressure on the  nervous 
284
RHEUMATIC GOUT.
centres.  Instances in point  may be found recorded in Sir
Benjamin Brodie's work 'On Disease of the Joints,'1 in Dr.
Macleod's chapter on  Capsular  Rheumatism,2 and in several
of the medical periodicals ;  but as all the cases are devoid of
interest, save only in  so far as they serve to  illustrate the
reality and danger of such an occurrence, I shall content my-
self by referring  to the fact of their having been recorded,
and impressing upon all those who may have in their charge
patients labouring under this disease, the necessity of taking
active and immediate measures  should headache,  vertigo,
somnolency, impaired  memory, or any other symptoms appear
to indicate commencing mischief within the cranium.  Should
such symptoms be accompanied, as they usually are, by the
subsidence or disappearance of  articular swelling, it may be
worthy of consideration, whether by the application of mus-
tard 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 inflam-
mation 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 appropriate treatment.   But in other
cases it arises  coincidently with, and  probably in  conse-
quence of the sudden subsidence of, the articular swelling;
and  then if  the system is depressed, it is rapid in its  prog-
ress, pus generating  in its character, and  little under the
control of medicine.  In such instances the whole virulence
of the poison appears to be concentrated 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 result from an accumu-
lation of pus and serum in the pleural cavity.
  Inflammation of the eye is another complication  of con-
siderable importance.   Some writers on rheumatism, as Dr.
Macleod, for instance, express  great doubts as to  the fre-
quency of its occurrence,  and, in confirmation of their opin-
1  Ed. 4. p. 51.
2  On 'Rheumatism,' p. 118. 
AFFECTIONS OF THE EYE.
285
ion, appeal to the fact, that its  existence is noted in 2 only
out of 520 cases of rheumatism,  which were collected by the
late Dr.  Haygarth.  It certainly is strange, that  in these
gentlemen's practice, the organ in  question  should have
escaped so completely ; but  the result of their experience
does not accord with that of the profession at large.  In true
rheumatism, indeed, the eye seldom suffers ; so seldom, that
I find no record of any affection  of that organ in more than 4
out of the 379 cases of acute and  subacute rheumatism
admitted into  St. George's Hospital during the time I held
the office of Medical Registrar.   But  in rheumatic gout the
eye is not  unfrequently implicated.   It was inflamed in 11
out of the 130 cases of rheumatic gout which were  admitted
into the hospital during the same period; and it has suffered
more or less severely in 5 out of 75 cases which have fallen
under my own care at the hospital.  In private practice, too,
within the last year, two gentlemen have consulted me for
the same train of symptoms.  Therefore, although inflamma-
tion of the  eye is comparatively rare in rheumatism, and even
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  exhausted  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 com-
posed.  The conjunctiva,  the  sclerotic,  the  choroid,  and
the iris,  are all  sometimes implicated before the disease is
arrested; but  more commonly,  if  the  patient is under med-
ical treatment, the choroid and the  iris escape altogether.
Very generally the inflammation commences 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 external cause.
Rarely, however, unless grossly neglected, does the inflam-
mation leave  permament 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  expedient  to  give calomel and opium, and to ap- 
286     TEMPERATURE, ETC., OF THERMAL SPRINGS.
ply  a blister or a  few leeches  to the  temples, but  more
commonly opiate fomentations to the eyes, with cold appli-
cations 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 ptyal-
ism,  aggravates rather than  mitigates  the disease,  and in
such cases the iodide of potassium and  cinchona may  often
be beneficially employed.   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.
Table
Exhibiting the Temperature and Constituents of various Thermal Springs*
       BATH WATERS.
Temperature. — Hot  Bath,  117°;
  King's Bath, 114° ; Cross Bath,
  109°.
Contents of a Pint:
  Sulphate of Lime
  Carbonate of Soda
  Sulphate of Soda
  Carbonate of Lime
  Silica   ....
  Oxide of Iron .  .
     Error .  .  .
 9-3 grs.
 3-4  ;,
 1-5  „
  •8  „
  •2  „
  •01985
  •11985

15-33970
(' An Analysis of the Bath Waters,'
  by Richard Phillips.)
      BUXTON WATER.

Temperature of the Bath, 77°.

Contents of a Gallon:
Sulphate of Soda  .
Muriate of Lime
   „     Soda
   ,,     Magnesia
Carbonate of Lime
Extractive matter and
  loss......
•63 grs
•57  „
 1-80
  •58
10-40

 1-20

 15-0
(Analysis by  Dr. Murray,  'Trans.
  Royal Soc. Edinb.,' vol. viii.) 
TEMPERATURE, ETC.,
OF THERMAL SPRINGS.     2S7
      BAREGES WATER.

Temperature, about 120° Fahr.

Contains :

    Sulphuret of Sodium.
    Carbonate of Soda.
    Sulphate of Soda.
    Muriate of Soda.
    Nitrogen.
    Free Sulphuretted Hydrogen.
    Animal Matter.
    AIX LA CHAPELLE.

Temperature, 130° Fahrenheit.

Contains in a Pint:
Sulphur ....
Muriate of Soda  .
Sulphate of Soda  .
Carbonate of Soda
Phosphate of Soda
Animal Substance
Silex.....
Fluate of Lime
Carb. of Lime
  „    Magnesia
  „    Strontian
31-946
(Analysis of the source de l'Empe-
  pereur, by Monheim.)

A Pint contains :

  Carbonic Acid   .  .    89 inches.
  Sulphuretted   Hy-
    drogen  .  .  .  .   13J   .,
(According to Kortum.)
    WIESBADEN WATER.

Temperature of Kockbrunnen Water,
  151° Fahrenheit.
Contains in a Pint:
• Muriate of Soda .
  Sulphate of Soda .
  Muriate of Lime .
  Sulphate of Lime .
  Carbonate of Lime
  Muriate of Magnesia
  Carb. of Magnesia
  Extractive matter
  Iron.....
  Muriate of Potash
  Filiate of Magnesia
(Analysis by Kastner.)
44-225  grs.
  •700   „
 5-480   ,,
  •420   ;,
 1-050   „
  •790   „
  •700   ,.
 1-750   ,;
  •078   .,
 1-200   ;,
 1.600   „

58-593   „
    BADEN-BADEN WATER.
Temperature  of Ursprung  about
  120° Fahrenheit.
A Pint contains:
  Muriate of Soda  .  .  17-500 grs.
     „      Lime  .  .   1-500   „
     „      Magnesia    -500   .,
  Sulphate of Lime .  .   2-750   „
  Carbonate of Iron  .    -Ill   „
22-361
(Analysis by Kastner.)
TEPLITZ WATER.	
Temperature, 114° Fahrenheit.	
A Pint contains:	
Sulphate of Soda .	1-696
Muriate of Soda .	•770
Carbonate of Soda	12-240
Carbonate of Lime	•340
	•420
Extractive . . .	•100
Carbonate of Iron	•036
grs.
15-608
(Analysis by Ambrozzi.) 
CHAPTER XII.
                ON CHRONIC RHEUMATISM.

  When describing the symptoms  of acute  rheumatism, I
remarked on the difference of the structures affected in dif-
ferent cases, and pointed out the reasons which induced me
to classify 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  co-exist 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 classi-
fication, founded simply on anatomical peculiarities, incon-
sistent with the pathological phenomena.   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 fascias and tendons, or the periosteum 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 re-
placed by synovial symptoms, and may ultimately terminate
in sciatica, or some other form of neuralgic pain, or in rheum-
atism 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 consti-
tution of the patient, the quantity of the  poison present  in
the system, and a variety of other modifying  circumstances.
Whatever its precise 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. 
LUMBAGO.
289
These are facts of every day experience, and receive constant
illustration in the wards of every large  hospital.  But ac-
cording 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 mus-
cular structures; but no  sooner are the acute symptoms
developed, than the muscular pains  subside, and the joints
are chiefly if not solely accepted.  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 impli-
cated.  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, what-
ever 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 tendons, more generally suffer in the chronic
form of the disease.  The  muscles may  be, and are, some-
times implicated in the acute disease, and the joints, in  like
manner, are not unfrequently attacked  during  the chronic
stage of  the  disorder; but the  distinction just alluded to
holds good so  generally,  that in practical importance mus-
cular rheumatism  ranks  far  above all other forms  of the
complaint, as it occurs in a chronic state.
   Chronic rheumatism, then, may be either a sequel of an
acute attack,  or  may commence at once as an idiopathic
disorder,  and preserve this character from first  to last.   In
the former case the joints are rarely  free  from pain ;  in  the
latter they frequently escape  altogether.  In both instances,
however,  the  disease is characterized by a dull aching or
uneasiness, wliich is aggravated or quickened into agonizing
pain by sudden motion of the affected 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
               19 
290
CHRONIC RHEUMATISM.
 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 sub-acute rheumatism,
 and have  been treated in accordance with  their sub-ncute
 character.
   One of the forms in which chronic rheumatism most fre-
 quently presents itself in practice, is that of lumbago.1  The
 patient who has  suffered perhaps from little else than stiff-
 ness in various  parts of the  body, is  seized with pain and
 aching across the  loins.  So long  as  he  remains quiet, he
 enjoys comparative immunity from suffering; but he under-
 goes 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 himself into a sitting posture : is  he
 seated in a chair ? he finds it equally difficult  to  rise  on to
 his feet:  and is  he  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.
   When the attack is severe, the unfortunate  sufferer may
 be obliged to remain in bed, or to lie on the sofa, for several
 successive  days;  and, in  such cases, there is  usually some
 amount of constitutional disturbance,  marked  by a  coated
 tongue, acceleration 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 in-
 stance, 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  exceedingly obstinate ;  and,  if
neglected at first, may linger on for weeks or months  in
 spite of any treatment wliich 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 complaint
which is commonly known by the appellation of a " stiff"  or
  1 The terms "form" and "variety" are employed as implying simply a
difference in the scat, and not in the real  nature of the disease. 
SYMPTOMS OF INTERCOSTAL RHEUMATISM.
a " 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 sometimes, when neglected, it continues ob-
stinately fixed in  one particular spot, and may then give rise
to distressing  consequences.  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
towards  the  affected side ;  and whilst in this  position, so
much rigidity of the muscles may ensue, as to render it diffi-
cult for him  to regain his former posture.  Such cases are
rare ; and, in my experience, have only occurred after re-
peated attacks, or where the disease has been grossly neg-
lected, 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 paiieties 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 pain-
ful.  Motion  greatly aggravates the pain.  Hence the suffer-
ing is 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
rheumatism 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 upwards 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 inter-
costal muscles are thus kept at rest; and by the absence of
those physical signs  of pleurisy  which are obtained by per-
cussion, and the careful 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 muscles, as naturally  leads to their gradual 
292
CHRONIC RHEUMATISM.
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 ben-
efit will ultimately result  from moving and exercising the
affected limbs, as also from employing electricity and fric-
tion, and from submitting to that more active process of
rubbing und kneading which is commonly known as sham-
pooing.
  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 sur-
rounding  the joints, 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 a dull aching
of the joints,  which, when roused and excited  by sudden
motion, is converted 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 bursas 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 wliich 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 bursas and the adjoining
tendinous sheaths are the seat of effusion, any action which
tends to bring the parts into play is certain to  be accompa-
nied by an increase of suffering.   In the chronic state, how-
ever, 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.
  There is yet another form of  this complaint which is 
SYMPTOMS OF PERIOSTEAL RHEUMATISM.       293
peculiarly apt to occur in cachectic conditions of the system,
and is well deserving of especial notice ;  I mean that known
as periosteal rheumatism.   In those parts of the body where
the bony frame-work is thinly covered with integument, the
periosteum, the fibrous investment of the  bones, is  apt to
become 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 somewhat swollen and puffy,
and as the puffiness subsides, the thickening to which I have
alluded ensues, and forms firm, irregular, painful elevations,
exquisitely tender to the touch.  So prominent 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, sufficiently 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, they are easily recognised, and their  nature
is not very liable to be mistaken, but their occurrence on
the forehead, 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 ex-
ceedingly obstinate and intractable.  Patients suffering under
this form of  disease have repeatedly come under my  care at
the Hospital, who, for months, have been undergoing treat-
ment for headache 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 occur-
ring only among those who are tainted with venereal poison,
or whose systems are saturated by mercury.   Nothing, how-
ever  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 there-
fore met with most frequently among those who have been
depressed by the operation  of a specific poison, or by long-
continued mercurial action.  But it is not necessarily confined 
294
CHRONIC RHEUMATISM
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
such 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 occasion 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  alleviation; and the  fact that an
exacerbation of  symptoms  towards  night is  equally  well
marked in  many other disorders, occurs under every condi-
tion 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 incorrectness
of the opinion which  would refer  to warmth or to bed and
blankets in explanation of this peculiarity.
  That,  in  many cases,  the pain is aggravated  by  heat,
whilst in others, it is relieved by the same means and to an
equal extent, is a matter  of  common every-day experience,
and theoretically is a fact possessing little value.  It accords
precisely with the observation which has been in many com-
plaints in which pain is  a prominent  feature,  namely, that
warm or tepid applications are more grateful in one instance
or at one period of the disorder, whilst cold ones are  more
grateful  and more serviceable at another.  But in practice
its importance is strikingly  manifest, and  has  been recog-
nized  ever  since  the  days of Aretaeus.  The  cases which
benefit most from warmth,  are those which occur chiefly
among persons of  a languid constitution ; and in such  per-
sons friction and  stimulating embrocations, together with
hot baths, and the internal administration  of stimulant and
sudorific medicines, prove eminently serviceable, and should, 
AGGRAVATED BY HEAT.
295
therefore, be resorted to  without delay.   But in those in
whom an 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 symptoms.
  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 per-
spiration 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 afforded by a copious per-
spiration, resulting from a  further  increase of temperature
induced by a vapour or a hot air bath.  If his pains have not
been prematurely removed,  they have at least been subdued
or mitigated for a time.
  In  the treatment  of chronic  as of acute rheumatism,  it
should be remembered that the disease is engendered  by a
poison resulting  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 judi-
cious practitioner should  constantly bear  in mind how com-
plicated 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 of it should work
efficiently.  He should endeavour 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.  If his patient be pallid, he should recollect how
deficient is the coloring matter of the blood, and whilst ad-
ministering  quina and  other  bitters,  or alkalies with occa-
sional alteratives, he should not  lose sight of the benefit to
be derived from the various ferruginous preparations.  Above
all  he should promote a free evacuation through the various 
296
CHRONIC RHEUMATISM.
channels by whioh  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 endeavour so to modify
their several secretions as that every noxious matter shall be
got rid of without 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 termi-
nation of his case 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 constitution, its efficacy is quite equal to its
reputation.  But it is seldom necessaiy, or indeed expedi-
ent, to administer it in such full doses as have been given
and recommended by some practitioners.   Dr. Elliotson, for
instance, " has known patients who took six drachms three
or four times a day;*" and many persons, following Dr. Daw-
son's example, have given it in half-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 afford-
ing 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 evacu-
ant, increasing the  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 reg-
ulated by the exhibition of opium.  But  in larger doses its
action  is more uncertain.  Dr. Elliotson, whilst asserting
that " when internal stimulants  are necessary in rheuma-
tism, he thinks this one of the best," acknowledges that,
when given in large  doses, " it often purges violently, and
sometimes produces the nettlerash;'" and although no seri-
ous consequences 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
  1 Mason  Good's 'Study of Medicine,' vol. ii, p. 281.  Note by Samuel
Cooper.
  a Loc. cit. 
TREATMENT BY PARTICULAR MEDICINES.      297
rheumatism from the ease with which, if tonics be required,
it may be combined with bark and other similar medicines.
But the Mistura Guaiaci, to which I alluded when consider-
ing the treatment  of acute rheumatism, is also a form in
wliich guaiacum may  be  advantageously employed ; the
more  so, when it is thought desirable to administer guaia-
cum freely without the quantity of the diffusible stimulant
wliich 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
existing in the compound formerly well known by the title
of the " Chelsea Pensioner."   The original recipe is  given
below ;l and in these, or in somewhat varying proportions,
this medicine has repeatedly effected a cure after all  other
preparations have been tried in vain.   It is especially useful
in old lingering cases, accompanied by torpor of the intesti-
nal secretions, and  a sluggish inactive condition of the skin.
  On  the same principle as  that on wdiich  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 Turpentine, Cajeput, and Amber, the balsams of
Copaiba, and Peru; and aromatic and pungent plants, such
as mustard, horseradish, and the Arnica Montana. All these
agents, either  alone,  or  in combination 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 terebmthm-
ate nature, and were  it not  for  its nauseous flavour, 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.
  Colchicum is of far less service here than in the more active
     1 Take of Flowers of Sulphur, §ij ;
            Cream of Tartar, § j ;
            Powdered Rhubarb, 3 >j ;
            Guaiacum, 3j;
            Clarified Honey, lb. j,
            One Nutmeg finely powdered.  Mix the ingredients.

  Two lar-e teaspoonfuls to be taken night and morning, and to be per-
severed n until the whole is consumed  For the first three nights a large
tumbler of warm rum and water to be taken at bed-time, or if fever be
present, white wine instead of rum. 
298              CHRONIC  RHEUMATISM.
form of the disease, and its administration should be restricted
to those cases  in  wliich the joints are principally affected,
and the pain is aggravated by heat.   Under  such  circum-
stances, 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 joints  are suffering.  In  no instances, how-
ever, are its virtues so conspicuous as in those in which the
periosteum is implicated.  In such cases, administered in two
or three 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 im-
provement.   Indeed, so potent is  the influence of this medi-
cine 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 advisable to  combine it with bark and sarsa-
parilla, and  to  exhibit  a full dose of opium at  night.  The
bowels, in such a case, should be regulated by gentle laxa-
tives, and general  health sustained by a  full and  nutritious
diet.
  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
influence.  I have sometimes administered it in half-ounce
doses when the patient has been  thoroughly out  of health;
and in some such cases with undoubted benefit.  But, under
ordinary circumstances, its efficacy has appeared  to me ex-
tremely questionable;  and now, whenever  a case occurs in
which,  from the  cachectic  condition of  the  patient,  its
administration seems likely to be attended with benefit, I
usually give it  in the form of an  emulsion  with the  Liquor
Potassee  and Iodide of Potassium ;l  or  else combine it,  if
1 The following i9 a form I frequently employ :
            Olei Morrhua?, 3 iij 3
            Liq. Potassa). n\xx;
            Potassii Iodidi, gr. iij ;
            Ess. Limonum, fltviij;
            Aquas distillatas, 3vij ;
                            M. ft. Haustus ter in die sumendus. 
TREATMENT BY PARTICULAR MEDICINES.       299
circumstances permit, with the syrup of the Iodide of Iron.
When  the appetite is indifferent,  the  circulation  languid,
and the pulse weak, the Sulphate of Quina, in  combination
with fifteen or twenty minims of the dilute Sulphuric Acid,
aided,  if necessary, by some preparations of Iron, has ap-
peared to me more generally useful.
  Hydrochlorate of Ammonia is a remedy of singular efficacy
in chronic rheumatism, yet, strange to say, is almost un-
known as such to the profession.  In no treatise on rheuma-
tism 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 effect of its
internal  administration.  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 " promotes  not  only the mucous se-
cretions, but also  cutaneous  exhalations."1  Certain it is,
that in fifteen or twenty grain  doses, in combination with
bark, it sometimes  produces marvellously good results, and
is frequently  serviceable when other  remedies  have proved
inefficient.  The character  of the secretions  improve under
its influence, the skin acts more freely and  regularly, and
the disease gradually subsides.  Its beneficial  effects, how-
ever, are most remarkably exerted in muscular  rheumatism ;
and when the periosteum or the joints are affected, it seldom
affords us much assistance.
  In some obstinate cases of chronic rheumatism, more  es-
pecially when  supervening in  a  system  which has been
poisoned by  the  syphilitic  virus,  it is expedient  to have
recourse to the exhibition  of mercury.  In ordinary cases,
however, mercurialization  is needless,  if not  hurtful.  It
sometimes proves useful when there is  excessive tenderness
with puffiness about  a periosteal  swelling, as  also when a
joint is enlarged, and continues in a state of irritation, unin-
fluenced by other remedial agents, but it is always depress-
ing,  and should not be employed unless its   influence is
demanded either by the urgency of the  local symptoms, or
by the failure wliich has attended the administration of other
remedies.
  Opium and other  sedatives seem especially called for in
  1 Handbuch der Speciellen Hu'.meltellehre.  Quoted in Percira's' Mate-
ria Medica.' 
300
CHRONIC RHEUMATISM.
chronic rheumatism, by the obstinacy and wearing  nature
of the pain, and certainly, in some instances, their influence
for good appears to extend not only  to temporary abate-
ment of suffering, but  to the  subjugation of that action on
which the  pain and suffering depend.  In my experience,
however, this has  rarely been the  case.  More generally
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
view with  which they should be administered,  and their
exhibition  should therefore 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
Morphias 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 Ipecacuanhas Compositus of the Pharmacopoeia.
  In that form of the disease  which is known as lumbago,
brisk purgatives are some  of  our most efficient  allies, and
should usually be made use of at the commencement of the
attack.   Their efficacy, however, varies  according  to  the
amount and character of the alvine and urinary secretions.
When the urine is scanty, high colored, or loaded, the bow-
els costive,  or the dejections dark colored and offensive,  they
are almost  always of inestimable  service, and a few doses
of Colocynth and Calomel administered at bedtime, followed
each morning or on every alternate day by a black draught,
containing  half an  ounce of the Potassio-Tartrate of Soda
and  thirty  minims of Colchicum wine, have often gone far
towards 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 frpm their employment
in such cases, that I now very rarely have recourse to their
administration.  In the former instances, the  pain is prob-
ably 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 
BENEFICIAL EFFECT OF LOCAL REMEDIES.       301
relation to their superficial position.  Though internal rem-
edies should not be neglected, our main reliance must be on
local  applications.   Cupping on the loins  is of essential
service, and dry cupping may be often beneficially employed
when it is not thought desirable to abstract blood.   Baths
are also valuable agents, particularly the warm  bath, ren-
dered  alkaline  by the addition of Carbonate of Soda or
Potash, as are also  fomentations, formed by placing across
the loins flannel wetted with an alkaline and opiate solution,
and covered with a piece of gutta percha.  Stimulating and
opiate embrocations1 are also very useful in obstinate cases,
as are also mustard  poultices, and plasters of a stimulating
and absorbent character.   In some  instances, after the more
active symptoms  have subsided, a simple flannel bandage
covered with oil silk to prevent evaporation, or a band of
Markwick's epithem worn across the loins, is sufficient to
afford permanent relief.
   Stiff-neck  is benefited by  the  same  sort  of remedies.
 Though in some few instances  leeches may be needed, yet
more generally, friction, with opiate aud stimulating embro-
 cations, followed by warm fomentations to  the part,  are
 sufficiently active  agents.  When  the disease is of recent
 occurrence,  a few  drops of Chloroform or  Chloric ^Ether
 may be held to the part in the palm of  the hand, until red-
 ness 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 nowhere, perhaps,
 displayed more strikingly than in chronic rheumatism  The
 warm-bath, either alone or rendered alkaline  by potash the
 hot-air bath, and the vapour-bath, have each their respective
 merits.  The latter two  have always  appeared to me the

    ■ Subjoined are two very useful forms of liniment for these cases :-
            R.  Olei Cajeputi,
                Tincnme Opii, aa 3ij;
Olei Terebinthinse, 3iv;   __„_..   ,
Linimenti Ammoniae, &.   M. ft.  Linimentum.
Liquoris Ammonia?, 3j;
Tincturae Opii, 3ij;
Tincturae Canthandis, 3nj;
Linimenti Saponis, 3x.   M. ft.  Linimentum.
And      &•  Liquoris Atnmonise, 3j
             Tincturae Opii, 3ij; 
302
CHRONIC RHEUMATISM.
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 100°, has been equally if not more beneficial to those
in whom warmth proves grateful and sedative.   It must be
remembered, however,  that the vapour and hot-air baths
have the  great advantage  of  being applicable while the
patient is lying in bed, and this, in  some instances, may be a
sufficient recommendation 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 myste-
rious agency of the Bath or Buxton waters 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.1
  Blisters have been recommended, and are  frequently em-
ployed for the relief of chronic rheumatic pains, and as,
with other remedies, their  repute  has  varied  according as
they have  been  properly or improperly made  use of.  In
muscular rheumatism they are  seldom of much service, and
are 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  bursas
which has passed into a  chronic form,  they are almost in-
dispensable for effecting a rapid cure.   In both  these latter
cases their application should be  followed  by the use of
the iodine paint  or of  the  iodine ointment before recom-
mended.
  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
1 See Table, page 286, of this Treatise. 
         BENEFICIAL EFFECT OF LOCAL REMEDIES.      303

these cases.   Nothing proves more serviceable in old-stand-
ing, painful affection of the joints, than warm opiate fomen-
tations ;  and not  unfrequently  liniments or  embrocations
prove equally beneficial.  Various prescriptions have been
already given, which, in my hands, have proved exceedingly
efficacious j1 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 exter-
nally, was a remedy much  in  vogue amongst 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 power-
ful 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 sub-
dued, and the remaining pain has appeared to be in some
measure 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  coun-
ter-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 seda-
tive ; and, in some instances, the only interval  of ease which
the patient obtains,  are the few hours  which immediately
follow its employment.  Sometimes, from the situation of
the pain, it  may be difficult,  if not impossible,  to  make
effective use of the ointment, and, in such cases, an alcoholic
solution,  formed  by dissolving from three to four grains of
aconitine in an ounce of rectified spirit,  and applied to the
part by means of a camel's hair  brush, proves an excellent
and efficient substitute.
  When  the fleshy parts  are principally affected, and the
1 Page 301 of this Treatise. 
304
CHRONIC RHEUMATISM.
 atient is unable, from the nature of his pursuits, to confine
 imself 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 Emplas-
trum  Arnicas Montanas,1  and the Burgundy pitch plaster;
and if it be considered desirable to  increase the stimulating
properties of the latter,  its surface may be sprinkled with
muriate of ammonia.  When the joints, the bursas, or the
periosteum are affected, the Emplastrum Ammoniaci c. Hy-
drargyro, is  generally of greater service.  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 suffer from cold and
atmospheric vicissitudes, that he should be warmly clad at
all times, and not only should the  parts most  apt to suffer
be  more  than  ordinarily protected, but  his whole body
should be encased in flannel, and, in winter, covered by that
warm woollen  clothing known under  the name  of fleecy
hosiery.
  Other expedients have been adopted occasionally for the
relief of old rheumatic pains, among which I may mention
electricity and  acupuncturation.  In my experience, how-
ever,  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 my patients; but so constant has been its failure, that in
the few  cases in which relief has followed its use, I  have
been induced to regard the pain as  of nervous origin, or its
subsidence coincidently with the use of electricity as a mere
coincidence.
  Observation has not supplied me with sufficient data for
an opinion as to the efficacy of acupuncturation.   On look-
ing over my note-books, I find only five cases in wliich I have
witnessed its application in muscular rheumatism. In four
of these it proved utterly  useless; in the fifth some amend-
ment shortly followed its use, but  whether as the result of
 1 This plaster is prepared by Twinberrow, of Edward Street. Portman
Square.
I 
   INFLUENCE OF ELECTRICITY AND ACUPUNCTURATION.  305

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. Churchill's opinion, and says, " it is
useful chiefly in  rheumatism of fleshy parts, and the more
so as the disease is  less  inflammatory."2   In France,  M.
Berlioz"5 has tested it largely, and  speaks most highly of its
virtues ;  as  does  also M. Jules  Cloquet, who has recorded
the history  of 91 cases  in which  it proved  of the  greatest
service.  1 am bound, therefore, to admit, that in some cases
it may prove eminently useful; but  I am satisfied by expe-
rience 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,  and  constant atten-
tion 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 healthy state of assimilation, and in stimulat-
ing the skin, the kidneys, and other excretory organs, to the
active exercise of their functions.   With the stomach  per-
forming its function 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 rheum-
atic pains  will  not  be  long  before they  take their  final
departure.   Many a  person who for years had suffered from
chronic rheumatism, has speedily got rid of this inveterate
  1 ' A Treatise on Acupuncturation,' &c.  London, 1828.
  2 ' Medico-Chir. Trans.,' vol. xiii.
  3 ' Memoires sur les Maladies Chroniques, les evacuations sanguines, et
I'acupuncture •' Paris, 18l<5.

                    20 
306
CHRONIC  RHEUMATISM.
enemy, by thus having  recourse to  nature's assistance, in
conjunction with the aid of judicious medical treatment.1
   1 Whilst these sheets were passing through the press, I met with the fol-
lowing 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 subsequent 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
                       RHEUMATISM.

   When rheumatism  attacks the  nerves or their fibrous
 envelopes, 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 mistaken for pain affecting  any of the
 other structures.  It is often somewhat  paroxysmal  in  its
 accession, and, though  varying in its character  in  different
 cases, is usually severe and very obstinate in its continuance.
 It is  sometimes 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 some-
 times attended by fever, but more commonly, although the
 patient is  "out  of sorts," the pulse, the tongue,  and the
 urine, do not deviate  greatly from the condition of health.
   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 pyriformia
 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, de-
 scends 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 usut
 ally 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 goesup stairs or attempts
 to walk  after sitting  in a cramped position.  In one case it
is of a dull, aching, or benumbing character, and wearies by
its long continuance rather than by its severity;  in  another 
308          SCIATICA, AND OTHER FORMS OF

it exhausts, not only by its obstinacy, but by the extreme
violence of the startings, accompanied by pains of an excru-
ciating  nature,  which  occur at intervals throughout the
attack ; whilst, in a third class of cases, it prostrates all the
energies of mind and body by the continued indescribable
torture 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 are, if possible, in-
creased.
  The disease, as already stated, is apt to prove very obsti-
nate in its continuance.  It may sometimes be subdued by
appropriate 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  expulsion,  and harasses the patient for  weeks or
months.  In truth, sciatica is one of those diseases  which, in
some  instances, depends upon  local changes, and in others is
connected with constitutional  causes, each one of which re-
quires 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  a
rheumatic irritation, or inflammation with effusion  of lymph
and serum into the sheath of  the  nerve, whilst that, again,
which, in such  a case, proves most beneficial, would, proba-
bly, exert  no curative influence  when the pain is dependent
upon  gastric or intestinal irritation, or upon local changes of
structure either in the nerve itself  or in neighbouring 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 mischief to be remedied.
  The complaints which are  most apt to be mistaken for
sciatica 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 
NEURALGIC  RHEUMATISM.             309
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 by pushing the head of the bone upwards
against  its socket, and after a time will be  accompanied by
fluctuation more or less  perceptible, often giving rise to a
fulness  in the groin, whilst the constitutional disturbance,
by  which it is  attended, will gradually increase with the
progress of the  disease.  By these symptoms alone the dis-
tinction between the two diseases is made sufficiently appa-
rent,  but it is rendered still more striking by the fact that,
in hip disease, the pain is rarely confined to the trunk of the
sciatic  nerve, and 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 shoot-
ing 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 testi-
cles,  with pain shooting down to the tip of the penis,1 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.   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 with  a
syphilitic taint ?  Has gout any share in its production ?  Is
it caused by gastric  or  intestinal irritation ?  Is  it symp-
tomatic of mischief in the brain ? or is it  dependent on an
alteration 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  rare occurrence, and as
givino-  rise to 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 
310          SCIATICA,  AND OTHER FORMS OF
detail  the symptoms  by which the operation of each  is
denoted.
   Thus, then, if the patient is thin, pale, sallow, and ex-
tremely sensitive to atmospheric vicissitudes; if he has expe-
rienced pain, or threatenings of pain, in other parts  of the
body;  if, at some former period, he has suffered from rheum-
atism  affecting  the joints;  and, above all, if his  present
attack is the result of exposure to cold and damp, the disease
under  which he  is labouring is rheumatic, and is to be re-
lieved  by vapour-baths, guaiacum, alkalies, and similar rem-
edies.   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 cer-
tainly of gouty origin, and is to be cured by colchicum, alka-
lies, 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 mercury, or experi-
enced  pain in his bones, the mischief is probably 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 en-
joyment of excellent health;  has his present attack been
preceded by constipation or irregularity of the bowels, by
flatulent distension,  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
loading of the intestines.  This opinion will be confirmed, if
the pain is confined to the right leg, for the disease not un-
frequently arises from unhealthy accumulation of faecal mat-
ter in the caput coli.   Such a  case as this is to be cured by
the administration of active purgatives, both in the form  of
enemas and by the mouth, together with such other medicines
as are calculated to carry off the irritating matter, and to pro-
duce 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 morn-
ing of  the fourth day by an enema, containing an  ounce of
spirits  of turpentine, or two drachms of assafcetida, or an
equal quantity of the confection of rue.
   Thus, then, according as one or other of these causes may 
NEURALGIC RHEUMATISM.
311
appear to have produced our patient's sufferings, the nature
and activity of the treatment must be varied.  But this is
not all.   In true sciatica, from whatever cause arising, very
different local  changes  may be  induced, and  very different
remedies required for their relief.  Be the affection rheuma-
tic  or gouty in its nature, or be it due  to  syphilis, or to a
distended colon, the pain in either case is due to a cause of
irritation, which may either give rise  to no perceptible local
change, or, on the other hand, may be accompanied by a co-
pious effusion of serum, or of serum mixed with lymph, within
the sheath of the nerve.  In the former  case, the means
already  mentioned as adapted to the  removal of the several
causes from wdiich the affection derives it origin, will be suffi-
cient  to effect a cure. But, in the latter, the disease is more
complex and less tractable.  The effusion here, is not, as in
ordinary rheumatism, of secondary importance; it takes place
within the sheath of the nerve,  presses upon the nerve, im-
pairs its function, and thus leads to malnutrition and wasting
of the limb ;  and if the pressure is not speedily removed, irre-
mediable alteration  of structure takes place, and the nerve,
hardened by long-continued pressure, is found after death
grey and shrunken.
  In  every case of sciatica,  then, the  existence or  non-
existence of  effusion within the sheath of the nerve is a
question of primary importance. If  no effusion exists, the
remedies before alluded to, as best calculated to remove the
different causes of irritation, will be the most efficient in
removing the irritation itself, with the pain and other symp-
toms  consequent thereon ; whereas, if effusion has already
taken place,  measures will be needed not only to allay ex-
isting irritation, and remove its  cause, but  to promote ab-
sorption of the effused fluid, and remedy the mischief it has

  By what .symptoms,  then,  are we assured of the exist-
ence of effusion ?  I know not  whether the  experience of
others corresponds with my own observations on this sub-
ject,  but such signal benefit has often been  derived  from
remedies applied in accordance with  the views I am about
to enunciate, that I cannot but think  them entitled to con-
sideration.                                    .
  At the commencement  of an  attack, no certainty can  be
felt as  to the  existence of fluid within  the sheath of the
nerve.  The probability of its occurrence, however, is in pro- 
 312          SCIATICA, AND OTHER FORMS OF

 portion to the severity of the local symptoms and the inten-
 sity of the febrile  disturbance,  and remedies  should  be
 selected and apportioned accordingly. If pain be the prom-
 inent feature  of the attack, and be unaccompanied by febrile
 symptoms, it  would be right to act as though no 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 effusion de-
 pends.   But  after the  disease has lasted longer, and  has
 passed into a  chronic form, we have more to guide us  to a
 correct diagnosis.   If  effusion is 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 by the fluid within
 its sheath, its  function is impaired, and the symptoms alluded
 to necessarily ensue.  Hence, when a patient who is suffer-
 ing 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 more especially when, in addition to these
 symptoms, there is more or less inability to move  the limb,1
 —the presence of fluid within the sheath of the nerve may be
 inferred, and steps should be taken to obtain its evacuation
 either by mechanical or medicinal means.  In such cases—
 and how common are they in practice !—I have repeatedly
 seen sedatives employed freely and pertinaciously, and vari-
 ous  anti-sciatica remedies  made use of with  the view of
 effecting 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 effusion present themselves,
 I always resort  to that method of treatment which, what-
 ever its modus operandi, is  entitled to the credit  of giving
 speedy relief.
  1 Inability arising from loss of power, and not as a result of excessive
pain. 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
complain that the limb is weak, and feels very heavy, and that therefore
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 sub-
dued, the effusion, the result of that inflammation, remains, presses upon
the nerve, and impairs its function. 
NEURALGIC RHEUMATISM.
313
  The measures which prove most efficacious in checking
the progress of the effusion, and promoting its absorption,
are cupping, leeching, and blistering, combined with the
internal  administration  of mercury  and  diuretics.   The
practice  of cupping, leeching, and blistering, for  the relief
of sciatica, was first introduced  by Cotunnius, a celebrated
Neapolitan physician,1 under the idea of evacuating an acrid
humour from the sheath of the nerve ;  and the comparative
disuse into which it has fallen, has  resulted, I believe, from
its having been at  one  time  recklessly employed.   It has
been  often resorted to without reference to the presence  of
fluid  within the sheath  of the nerve; and even in cases
attended by effusion, its good effects have been counteracted
by unrestrained movement of the limb, and by the exhibi-
tion of stimulant and tonic medicines, instead of being aided,
as they always ought to be, by the administration of mercu-
ry, and other medicines  having  a tendency to promote the
absorption of the  effused fluid.   Moreover, it was formerly
the practice to make use of issues, rather than of blistering ;
and as their only effect was, as  Dr. Seymour remarks, " to
add additional distress to unrelieved pain," it is not surpris-
ing that discredit should have been thrown on this  whole
system of treatment.  Employed,  however, with judicious
discrimination, no remedies are  capable of  affording greater
relief. When, from the  activity of the febrile disturbance,
the severity of the  pain, and the sense of local heat which
attends it, it is probable that effusion 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 mercu-
rials,  and purgative  and  cooling  diuretic  medicines,  should
be resorted to early and vigorously.   On  the other hand,
when all febrile symptoms have passed  away, when the effu-
sion is of some duration, and is  probably due to causes no
longer in  existence, then  mercurial action should be  slowly
induced,  and blisters should be used in preference to, if not
to the exclusion of cupping and leeching.  Indeed, in such
cases, vesication is,  of all local  remedies, the most import-
ant, 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 with powdered morphia to relieve the  pain.  In

  1 Cotunnius de Ischiade Nervosa Commcntarius.'  8vo, Viennse, 1770. 
314          SCIATICA, AND OTHER FORMS OF
some instances, however, morphia applied in this  manner
appears to aggravate, rather than to allay the  pain; and
when such is the case, its use should be discontinued.1
  There is one local  application of singular efficacy in the
cure of sciatica, connected with effusion into the sheath of
the nerve—I  mean  that  known  as  acupuncturation.  Its
virtue depends  upon the mechanical  assistance it  affords
towards the evacuation of the fluid.  Whilst 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 the 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 complete 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, to imperfect
manipulation, whereby the sheath of the nerve has escaped
unpunctured, and in some to the widely  differing  circum-
stances under which the operation has been undertaken.  If
resorted to when no  effusion  exists, or whilst any trace  of
inflammation remains, it cannot be and is not  practically
useful.2  Indeed, in the latter case, it  will probably act pre-
judicially;  whereas,  if employed when inflammation has
subsided, and the nerve is irritated by the unwonted press-
ure  of the effused  fluid,  it promises speedy and effectual
relief.
  Of all remedies, however, those which come most gene-
rally and most beneficially to our  aid, if not  in  curing the
patient, at least in mitigating the  severity  of  his sufferings,
are sedatives,  with  opium and belladonna at their head.
Opium, with the various salts of morphia; belladonna, given
  1 On several occasions, when the pain has been increased, I have discov-
ered that the acetate or some other salt of morphia has been employed,
instead of the pure morphia, which has been ordered, and I am inclined to
think that the ill-success which has attended its application has been attrib-
utable, in great measure, to this cause.
  2 In this statement, I am borne out by Dr. Elliotson, who says " I have
never seen it beneficial in any inflammation or inflammatory pain." (' Med.-
Chir. Trans.') 
NEURALGIC RHEUMATISM.
315
internally and applied externally,—henbane, conium and
stramonium, aconite and veratiia,—these are among the most
powerful and most efficient of our allies.   But they appear
to be so only in so far as they tend to diminish nervous irri-
tability, to allay suffering, and procure that repose which is
absolutely necessary for the proper maintenance of the func-
tions of life.   Their value depends upon their power of tem-
porarily assuaging pain, 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 medi-
cines ; 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, are  practically inoperative for good.   It
then becomes expedient  to  have recourse to some  other
substances of  the  same class, and belladonna, stramonium,
hyoscyamus, and  conium,  may be employed  as  occasion
requires.  Belladonna  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 sixth to a third 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 excessive  depression of  the vital powers.  It
should, therefore,  be  employed with extreme caution, the
patient being  watched throughout the period of its adminis-
tration, 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. 
316          SCIATICA,  AND OTHER FORMS OF

  But it is not only from its internal  administration that
benefit may be obtained in these cases ; the greatest advantage
is sometimes 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 eleven  drachms of
laudanum,  half a drachm of which is to be painted along
the course  of the nerve  night and morning.  But in  what-
ever  form  it 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  produce excessive dryness of the fauces,
with giddiness, dimness  of vision,  and other early symptoms
of narcotic  poisoning.
  Stramonium, which was first recommended by 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 rheum-
atic, the extract produces 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 uncer-
tain ;  and is accompanied now and then by exeessive dryness
of the throat and fauces.
  The hyoscyamus niger and the  conium maculatum, yield
tinctures and extracts  possessing sedative qualities  well
adapted for the relief of this painful disease, but not possess-
ing, 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, thev 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 should, there-
fore, be reserved for those cases in wliich there is something 
NEURALGIC  RHEUMATISM.
317
to contra-indicate the employment of those which are more
powerful and more efficient.
   Of the internal administration of aconite and veratiia in
these cases, I have had  a  very limited experience,  having
watched their effects only in  some few cases in hospital
practice.   My observation, however, as  far as it has gone,
has  not led  me to form a very favorable  estimate of their
virtues.  In  one  or  two instances some improvement  has
taken place under the influence of from five to fifteen minim
doses of the tincture  of aconite, and of from  one quarter to
two thirds of a grain of the extract administered twice or
three times a day, as also, though in a less marked  degree,
from the tincture and extract of veratiia, in about the same
doses.  But  the benefit resulting from their action has been
so uncertain and questionable, and the risk incurred  by
their exhibition  is  on  all  hands admitted  to be  so con-
siderable,1 that  I rarely have recourse to  their  internal
administration. Externally, however, they maybe employed
more frequently, as in this form their beneficial influence
is often strikingly displayed.  Store than once the tinctures
or the alcoholic solutions of aconite and veratiia,  applied by
means  of  a  camel's  hair brush,2 or ointments  containing
their respective alkaloids,  aconitina and veratiia,3  rubbed
nio-ht 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 inconvenience. Very
different results,  however,  have attended their  use in dif-
ferent cases.   On no occasion in wliich they have been tried
during the active stage of the disease, have they exercised
the  slightest influence  for good ; but their power has been
exerted very conspicuously in  obstinate cases, which have
  1 For a remarkable illustration of this fact, see Dr. Seymour's observa-
tions on ' Severe Diseases of the Human Body,' p 243.
  3 The formulae I usually employ are for the alcoholic solutions:
     Aconitina3,gr.vj;                  Or Vcratnae, gr. xx.
     Spir. Rectificati, 3j.  Misce.
  8 For the ointments:—                .
     Aeonitinaa, gr. x j         Or V eratnae, gr. xxxv,,
     Adipis prreparata?, 3vijss;
     Olei Olivas, 3ss;
     Olei Bergnmotti, V[x;
     Olei Santalaj, mij.  Misce. 
318          SCIATICA, AND OTHER FORMS OF
tormented more  by their long continuance  than by the
severity of their symptoms.
  Various other  external applications have been tried for
the  relief of this  painful malady.   Thus  galvanism and
electricity have each had their advocates, and have by some
been lauded as  much  too extravagantly as they have  been
too indiscriminately abused by others.  The fact appears to
be, that  they exert no control over the progress  of the
disease, and tend possibly to aggravate it,  if used before the
active symptoms  have  subsided; but as soon as  the sensi-
bility of the nerve has been subdued, and while the patient's
limb is weak and stiff from long-continued inactivity, they
then  supply a stimulus, which assists materially in  main-
taining its nutrition and restoring its healthy function.
  In like manner, cold has found eager partisans, who have
insisted on  its value as an external  application.   I cannot,
from  experience,  speak of its  effects when  so applied, but
it  may possibly  be  useful in those  cases which are aggra-
vated by warmth, and accompanied by a distressing sense
of local heat.
  Terebinthinate and Camphor liniments, and various stim-*
ulating oils, has been lauded as components of anti-sciatica
embrocations, and,  in  some few instances, have  been pro-
ductive of temporary relief, through their agency as counter-
irritants.   In my  hands,  however,  anodyne applications
have  been much more uniformly successful.  A strip of
flannel, soaked in equal  parts  of laudanum and  Hoffman's
asther, placed along the course of  the  nerve,  and  then
covered so  as to prevent evaporation, has often been the
means of mitigating the severity of a paroxysm in a marvel-
lously short space of time, and, in  some few instances, has
arrested  the disease.   Chloroform,  employed in  the same
manner, has also proved extremely serviceable.
  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
mischief, baths,  if not wholly inoperative for good, are  at
all events inadequate to effect  a cure.  So, also,  when the
pain is attributable to  gastric or intestinal irritation, baths,
if serviceable, prove so by promoting  free cutaneous action,
and thus improving the general health, more than by any
direct local influence  they exert.  But when the origin of 
NEURALGIC RHEUMATISM.
319
the mischief is rheumatic, and the blood is  charged with
the  morbific  element,  hot-baths, and  vapour 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 towards effecting the eradication
of the disorder; and cold bathing, more especially in salt
water, is an  excellent  adjuvant to medicine, in imparting
vigor to the system, and enabling it to throw off the remnants
of the malady.  In  Russia the occasional use  of a hot-bath,
or a  vapour-bath, immediately followed by a shower-bath,
or an ordinary water-bath, cold or tepid, according to cir-
cumstances, has a great repute as a powerful  restorative  of
a healthy cutaneous circulation, and this, together with cer-
tain  other  forms of rational  hydropathy,  in which  strict
attention to the daily routine of life, rational habits, rational
diet, rational  exercise, and rational repose,  play an import-
ant part in the restoration of health, will often enable us  to
effect a cure,  even when our best-directed efforts, when un-
assisted  by these potent auxiliaries, have proved quite  una-
vailing.
   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  com-
 fort ; and their efficacy may be increased by the addition of
 an alkaline and opiate  solution, as recommended in a previ-
 ous Chapter.   When the disease has assumed a chronic form,
 douches of hot, cold, or tepid water, or douches of vapour,
 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-establish-
 ment of their healthy function.
   On the same principle on which shower-baths have  been
 found beneficial, various tonic medicines, such  as quina,
 iron  and  arsenic,  have proved  serviceable  in  patients of
 broken  health or weekly constitution.   But they are not all
 equally useful in every case.   Quina appears  to be the most
 efficient remedy, in proportion as the appetite has  been bad
 and the attacks  more or less distinctly intermittent, whilst
 iron proves  most useful in pallid or anaemic persons with a
 weak pulse and a feeble circulation.   Arsenic is most serv- 
320          SCIATICA, AND OTHER FORMS OF

iceable to those in whom the attacks have been paroxysmal,
and accompanied by symptoms of a nervous character.   Sel-
dom, 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  pri-
mary  mischief has  risen.   Alkalies,  colchicum, and ano-
dynes, are  as  necessary here 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.   With-
out the previous  administration of medicines such as these,
to subdue present irritation and provide against  the further
generation of  the poison, quina and arsenic may be  given in
vain; and, in like manner, anodynes with colchicum,  and
other anti-rheumatic medicines, may be ineffectual in afford-
ing permanent relief, unless followed by a course of tonics.
  I  have hitherto spoken only of affection of the great
sciatic nerve, because it affords some of the  best examples
of this particular  form  of rheumatism. But the brachial and
the facial nerves are also  not unfrequently implicated, and
there are some points relating to their affection which re-
quire a passing notice.   It must always be remembered that
here, as  in sciatica, the  complaint 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 con-
nected with 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 sum-
moned to the relief of a patient suffering from either of these
forms of disease, the  first point to be ascertained is  that the
disease is really what  it appears  to be, an affection of the
nerves and their fibrous sheaths, and not pain symptomatic of
distant mischief.  This being determined, the same general
plan of treatment  should be pursued as has been already rec-
ommended for the cure of sciatica.  When the facial nerve
is affected, quina,  iron,  or arsenic, with a  sedative at night,
and an occasional morning laxative, are usually the most
efficient internal remedies, and their salutary effects may be 
NEURALGIC RHEUMATISM.
321
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 aether,
applied in the palm of the hand  to the seat  of pain, some-
times exerts a magically  soothing influence, and sometimes
the external application of hydrocyanic acid is attended with
the happiest results.1  When the brachial 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
the use of the  aconitine ointment than from any other exter-
nal application.
   It may be readily conceived that the class of remedies just
pointed out, are of little avail when the pain is symptomatic
of distant mischief.   When  the  pain in the  arm is symp-
tomatic of threatening mischief within the cranium, remedial
measures can afford  little relief, unless administered with due
regard to the regulation of the circulation through the brain.
When it  is  referable, as, alas! is  too frequently the  case, to
organic disease of the heart, or the large vessels, it is vain to
hope for relief from  Arsenic, Quina, or local sedatives, which
exercise no  influence on the central organ of the circulation.
In such a case as this, our only hope of affording assistance
to our patient, rests entirely on  our power of tranquillizing
the excited  circulating apparatus  by the cautious abstraction
of blood ; by  the administration  of such medicines  as  are
known  to control its irritability; or  in some  instances by
the exhibition of Iron and other remedies which are cal-
culated to augment the muscular power of the heart, and
so to enable it to do its work more readily.   In like man-
ner, when neuralgia affecting the face is attributable to dis-
ordered gastric secretions, all ordinary anti-neuralgic remedies
must  necessarily prove inefficient as curative agents.  Only
a few weeks since, a woman, ast.  33, was admitted a patient
under my care at St. George's Hospital, suffering from facial
neuralgia of four years' duration.  During the whole of this
long period  she had never been entirely free from pain, and
at intervals  had suffered most severely.  She had undergone
  1 A lotion composed of two drachms of the Pharmacopoeia acid, in com-
bination with six drachms of Rose Water, painted on the seat  of pain by
means of a camel's h nr brush, is an application which I have often found
useful.
                     21 
322
NEURALGIC RHEUMATISM.
 treatment on several occasions without relief, and had ex-
 hausted the catalogue of anti-neuralgic remedies ;—Arsenic,
 Quina, Iron, Opium,  Belladonna,  Stramonium,  and various
 local applications.   In  addition to this, she had  submitted
 to the extraction of six sound teeth, in the hope of obtaining
 relief.  But it was all to no purpose.  The pain continued un-
 abated ; and when I first saw her the general health was begin-
 ning to fail from her long-continued suffering, with the want of
 rest consequent thereon. On looking into her mouth, with the
 view of ascertaining  whether some  partially decayed  tooth
 might not be the source of all her suffering, I was struck by the
 immense accumulation of tartar on her teeth ; the whole of
 the teeth  of the lower jaw were  perfectly imbedded in it.
 As such a condition is closely connected with derangement.
 of the  digestive organs, I was led to make strict inquiries
 respecting the state of her stomach and bowels, and it then
 appeared, that for years she had suffered more or  less  from
 constipation, with  dark-coloured,  lumpy, offensive evacua-
 tions, and a sour disagreeable taste in the mouth.  This dis-
 covery induced me  to hold out the  cheering prospect of a
 cure, inasmuch as it appeared probable that the facial neural-
 gia was dependent on this disordered state of the gastric and
 intestinal  secretions, and would therefore be relieved coin-
 cidently with improvement in that quarter.  Nor  were my
 hopes misplaced.  Under the use of alterative doses of mer-
 cury, with gentle  laxatives,  and  a  steady perseverance in
 alkalies, vegetable  bitters, and the occasional  use of the
 warm  bath, the character of the  intestinal  secretions  im-
 proved, and the pain in the face subsided.
  Thus by careful attention to the  general features of a case
we may generally recognize the true nature of the symptoms,
and obtain some clue to their source; and when once we are
thus enabled to adapt our remedies to the exigencies of each
case, we shall seldom fail in affording relief. 
 
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