of the operation, however, the simple question is, are lives ever saved by it? This question is undoubtedly to be answered in the affirmative. The question, how many lives are saved, is of less importance in its practical bearing. If lives are ever saved by tracheotomy or laryngotomy in diphtheria, a practitioner is reprehensible if he allow a patient to die from laryngeal obstruction without opening the larynx or trachea. The patient is entitled to the chance of being saved by an operation, however small that chance may be.

The propriety of precautions against contagion has been already referred to. When practicable, removal, especially of persons between three and twelve years of age, beyond the epidemic prevalence of the disease is to be enjoined.

CHAPTER X.

Acute, Articular Rheumatism-Clinical History-Pathological Character-Causation-Diagnosis-Prognosis-Treatment-Subacute and Chronic, Articular Rheumatism-Muscular

Rheumatism.

THE term rheumatism is used to denote a constitutional disease characterized by certain local manifestations seated in the articulations and the fibrous tissues in other parts; the term has also been applied to neuralgic and other affections supposed to arise from the constitutional morbid conditions existing in the ordinary form of the disease. I shall consider, first, the affection to which the term rheumatism is par excellence applied, viz., acute, articular rheumatism; second, the affection, or affections, called subacute or chronic rheumatism; and, third, the affection known as muscular rheumatism. The disease called gout is in certain respects analogous to rheumatism, although presenting essential points of difference. After having considered the several forms of rheumatism just named, I shall consider gout, and, finally, an affection in which phenomena of rheumatism and gout are combined, as denoted by the name, rheumatic gout.

ACUTE, ARTICULAR RHEUMATISM.

Acute, articular rheumatism, as the name imports, involves an affection of the articulations or joints. The affected joints present the phenomena of inflammation. The lining membrane of the joints is, in fact, inflamed, but rheumatic inflammation in this situation has certain peculiarities, viz., it rarely leads to the exudation of lymph, to suppuration or structural lesions, and the inflammatory condition not infrequently completely disappears in the course of a few hours. The disease per se very seldom if ever proves fatal; but in cases in which life is destroyed by concomitant affections of internal organs, the affected joints are found to present, as a rule, only more or less effusion, which is sometimes opalescent, within the articular cavity, with thickening of the synovial membrane, and infiltration of the surrounding parts. Aside from these appearances the disease has no ascertained, constant, anatomical characters, except that the quantity of fibrin in the blood is notably increased. In the course of the disease certain internal organs are liable to become inflamed. The inflammation is generally seated in the fibro-serous tissues, and especially in the endocardium and pericardium. The

inflammation in these situations differs from that of the joints in this, viz., it is apt to give rise to the exudation of lymph, and sometimes to suppuration. In a pathological view, the endocarditis, pericarditis, and other internal inflammations which occur in cases of acute articular rheumatism, are local manifestations of the disease, like the arthritic affections, but it is most convenient to consider them in the light of complications.

CLINICAL HISTORY.-Acute, articular rheumatism, in the majority of cases, commences with a sudden attack. Of 16 recorded cases, under my observation, which I have analyzed with reference to this point, in 9 the attack was sudden, and in 4 it occurred in the night time. In a certain proportion of cases, febrile movement, more or less marked, precedes the local manifestations for a period varying from a few hours to one or two days. Hence, one reason for the name rheumatic fever, instead of acute rheumatism. In most cases, however, the fever and the local manifestations are simultaneous in their occurrence. Sometimes pain and soreness of the joints precede the development of the disease for a variable period.

The development of the disease is denoted by an affection of one or more of the articulations. The local phenomena are pain, tenderness, increased heat, swelling and redness of the skin. The pain differs in intensity in different cases, but, as a rule, it is not intense so long as the parts are perfectly quiet. Pain is especially excited by movements of the affected joints. In severe cases the slightest motion is insupportable; even jarring the bed or room occasions suffering. Pressure over the joints is painful. Owing to the pain occasioned by movements, the patient feels obliged to maintain, as long as possible, a fixed position; changes of the decubitus cause often extreme suffering. Swelling is most apparent in joints not covered with muscle, viz., the knee, wrist, elbow, ankle, and the smaller joints of the hands and feet. It is less apparent in the hip and shoulder. The swelling is due, in part, to a morbid increase of liquid within the synovial cavity, and in part to effusion into the surrounding structures. The redness is due to an erythema in the form of patches or zones, which do not present well-defined borders. The redness, like the swelling, is not apparent over the hip and shoulder, but only over joints comparatively superficial. The swelling and redness are, in general, proportionate to the acuteness of the rheumatism.

In some cases several joints are affected either simultaneously or in quick succession; in other cases the affection is limited to a single joint for a greater or less period. In the course of the disease, in most cases, various joints are successively affected, and frequently a greater or less number of joints are affected at the same time. It is a peculiarity of the rheumatic inflammation to leave one or more joints abruptly, the local phenomena sometimes disappearing within a few hours, and to attack as abruptly other joints. Different cases differ as regards the number of joints affected in the course of the disease; in some cases few or no joints escape, and in other cases the rheumatic inflammation is limited to a few joints or to a single joint. The fibrous tissues elsewhere than within and around the joints, and exclusive of the visceral organs, are liable to be attacked. Thus, those of the dorsum of the hand and of the instep, the ligaments of the neck and back, and the sclerotic tunic of the eye are sometimes involved.

The disease is extremely irregular as regards the number of joints affected, either simultaneously or successively, the order in which they are attacked, etc.; yet, the local manifestations are governed by an important pathological law, viz., the law of parallelism. Corresponding joints are often affected together, and when this is not the case, the different affected joints are either on one side of the body, or joints on the two sides which are analogous,

viz., the knee and elbow, wrist and ankle, hip and shoulder are affected in combination. In an analysis of 21 cases with reference to this point, out of 88 instances in which either a joint was affected singly or more or less joints affected in combination, there was but a single violation of the law of parallelism. This disease, therefore, is eminently one of the bilateral or symmetrical diseases. As respects the relative liability of the different joints to become affected, the analysis just referred to showed the order to be as follows: The knee, ankle, wrist, shoulder, hip, elbow, phalangeal joints of hands, do. of the feet, and the maxillary joint.

Acute, articular rheumatism is always accompanied with more or less febrile movement. As already stated, the disease is sometimes called rheu matic fever. In addition to the fact that the fever sometimes precedes the local manifestations, a reason for the propriety of this name is to be found in the fact that the intensity of the febrile movement is not always in proportion to the number of joints affected or the intensity of the rheumatic inflammation, as denoted by pain, soreness, heat, etc. The researches of Louis show the fever to be less intense, as a rule, than in typhoid fever, pneumonitis, the eruptive fevers, and erysipelas of the face. The pulse rarely exceeds 90 per minute. The temperature, as shown by the thermometer in the axilla, according to the observations of Dr. Sidney Ringer, of London, vacillates irregularly between 102° and 110° Fahr. Sweating is generally a symptom more or less prominent, occurring especially at night. The sweat emits a notably sour odor. The appetite is either lost or greatly impaired. Thirst is more or less urgent. The tongue is frosted or coated. The saliva becomes acid. Generally the bowels are constipated, but exceptionally there is diarrhoea. The urine is diminished in quantity; its specific gravity is high, owing to increase of urea and decrease of water; the coloring matter is increased, and, on cooling, the urates are deposited in abundance. The chlorides are sometimes deficient, and occasionally the urine is slightly albu minous. Pain in the head is not common. The intellect, as a rule, is not disturbed unless a cerebral complication occur, which is rare; but mild delirium is sometimes observed. In general, the strength is well preserved. Vigilance is usually a source of discomfort and more or less prostration, sleep being prevented by pain on change of position, and copious perspirations.

An important feature of acute articular rheumatism is its tendency to invade certain of the structures of the heart. Endocarditis occurs in a considerable proportion of cases. It is, however, less frequent than has been supposed by some, as already explained in treating of this affection. The inflammation, as a rule, is limited to the membrane lining the left cavities of the heart, and it affects especially the portion of this membrane which enters into the composition of the mitral valve. In a large proportion of the cases of valvular lesions of the heart, more especially mitral lesions, the point of departure is rheumatic endocarditis. Pericarditis occurs less frequently, the proportion being about one-sixth. As a rule, when pericarditis becomes developed, endocarditis coexists. For a consideration of these affections, as developed in rheumatism, the reader is referred to the section devoted to diseases affecting the circulatory system. It may be repeated here that pericarditis and probably endocarditis sometimes precede the local manifestations elsewhere, for, although it is convenient to speak of these affections as complications, they are, properly speaking, to be reckoned among the local manifestations of the disease; that is, they are dependent on the same internal,

Analysis of twenty-one cases of articular rheumatism, by the author. Buffalo Medical Journal, March, 1854. 3 Vide page 273 and page 264.

2 Aitken, op. cit.

determining cause to which the affection of the joints is to be referred. The structures of the heart and other internal organs are not affected in consequence of a change of place from the joints, or a metastasis, as formerly supposed, but in consequence of an elective affinity in the disease for certain tissues, among which the endocardium and pericardium are included. But it is to be noted that rheumatic endocarditis and pericarditis differ from rheumatic arthritis in this, they present, as a rule, the ordinary results of inflammation, viz., exudation of lymph, formation of false membrane, and sometimes suppuration, results extremely rare in the articular manifestations. The structures of the heart are apt to become involved in proportion to the acuteness of the rheumatism. They may become involved at any period in the course of the disease, but the liability is greatest in the early and middle period.

Bronchitis, pleuritis, and pneumonitis are occasionally developed. They are, however, so rare that it may be a question whether they be not accidental complications. Of 21 cases which I analyzed several years ago, and 13 cases more recently analyzed, the disease in the latter cases being left to pursue its natural course, making in all 34 cases, pneumonitis occurred in only one case; and these cases furnished not a single example of pleuritis, irrespective of pneumonitis, nor a single example of bronchitis.

The meninges of the brain are sometimes affected. Examples, however, are extremely infrequent. Active delirium, convulsions, and coma are events which have been observed in a small number of cases. In some of these cases the appearances denoting meningitis have been found after death, but in other cases the cerebral structures were devoid of the evidence of inflammation. The events just named are sometimes associated with pericarditis, and are probably connected pathologically with the latter affection. It may be conjectured that rheumatic inflammation may attack the meninges of the brain, leaving no traces after death, as has been observed with respect to the joints. There is also room for the supposition that, in some cases, delirium, convulsions, and coma may be due to uræmia, disease of the kidneys being accidentally associated with rheumatism. That the morbid condition of the blood proper to rheumatism may determine these events toxically, as conjectured by Fuller and others, is hardly probable in view of the infrequency of their occurrence.

The duration of acute, articular rheumatism varies greatly. The disease ends from self-limitation; but the minimum and maximum of duration are widely apart. In 1862, I observed at Bellevue Hospital 13 cases which were allowed to pursue their course uninfluenced by therapeutical interference, palliative remedies being alone employed. The duration in these cases, respectively, from the date of attack to convalescence, excluding the case in which pericarditis and pneumonitis occurred, was as follows: In three cases under 15 days, in one case between 15 and 20 days, in three cases between 20 and 25 days, in three cases between 25 and 30 days, and in the remaining two cases 45 and 56 days. The mean duration was a fraction under 26 days. Of 18 cases, treated in different ways, analyzed with reference to duration in 1854, not excluding cases in which the cardiac structures were affected, the minimum duration was 7 days, and the maximum duration 47 days. The mean duration in these cases was a fraction over 17 days.

The illness of patients affected with rheumatism may be indefinitely prolonged by pericarditis and pleuritis. But of the cases which I analyzed in 1854, embracing five cases of endocarditis and one case of endo-pericarditis,

1 Vide A Contribution toward the Natural History of Articular Rheumatism, by the Author. Am. Journ. of Med. Sciences, July, 1863.

the minimum duration was 7 days, the maximum 26 days, and the average duration was a little less than of all the cases, viz., a fraction over 16 days.

A peculiarity of rheumatism is, it does not, like the essential fevers, for example, pursue a steady continuous march from the beginning to the end, but its course is often marked by notable fluctuations as regards the general and local symptoms, more especially the latter. Not infrequently, after a few days, the affected joints are nearly free from pain, soreness, etc., the febrile movement subsides, and convalescence appears to be near at hand, when, suddenly, the local manifestations and the fever are renewed with perhaps as much or even more intensity than before. This may occur repeatedly during the career of the disease.

PATHOLOGICAL CHARACTER.-In view of the number of parts in which the local manifestations are often seated, the apparent migration of the inflammation from part to part, and more especially the observance of the law of parallelism in the arthritic phenomena, it is a reasonable supposition that the pathology of the disease involves a morbid principle in the blood. The view now held by most pathologists is, that a materies morbi does exist in the blood. With respect to the nature of the morbid material all pathologists are not agreed. It has been supposed to be uric acid; but an analysis of the blood in forty typical cases of rheumatism, by Garrod, failed to show the presence of this principle in larger quantity than exists in health, whereas, in gout the presence of this principle in a morbid quantity is demonstrable.' Others have adopted the supposition of Prout, that the morbid principle is lactic acid. The majority of pathologists at the present moment appear to regard this supposition as probably correct, and it is generally accepted as a rational basis of treatment. The supposition is, however, in the existing state of our knowledge, hypothetical; that is, its correctness is yet to be established by demonstrative proof. Assuming the hypothesis to be true, it is evident that the presence of lactic acid in the blood is an effect of morbid conditions of which nothing positive is at present known. Lactic acid is supposed to be formed during the destruction of sugar in the lungs in health; it may be conjectured, therefore, that its presence in the general circulation depends on circumstances which either occasion its undue formation or which interfere with its entering into combinations leading to its disappearance. It has also been conjectured that the lactic acid is formed in the disassimilation of the gelatinous and albuminoid tissues. Discussion of these or other conjectures would be here out of place; suffice it to say that the morbid principle in the blood, whatever it may be, is doubtless an intrinsic production; that is, it is not received from without the body. The pathological essence of the disease underlies the production of this principle. So long as its production goes on, the career of the disease continues, and the disease ends when the principle is no longer produced. This principle, circulating with the blood, acts upon certain parts and gives rise to the local manifestations of the disease, and in its action upon parts it shows an election for the fibrous tissues and especially those entering into the composition of joints.

CAUSATION-Rheumatism is one of the diseases supposed to be frequently, if not generally, caused by suppression of the functions of the skin, and attributed especially to the action of cold upon the surface of the body. This view of the causation has but little foundation. It is true that patients are apt to refer the disease to cold, but they are often led to fix upon some par

1 On Gout and Rheumatic Gout. London, Second Edition, 1863.