the blood is supposed to be involved in both forms. It is to be presumed that this principle is produced in less quantity when the disease is subacute and chronic, but it continues to be produced for a longer period, or it is reproduced after shorter intervals. In the cases in which anchylosis, distor tions of the limbs, and atrophy of muscles have resulted from the long continuance of the disease, these results remain, although the rheumatic disease may not continue.

The chronic form of the disease sometimes follows the acute, but this is not the rule; in the majority of cases the disease is subacute from the first. The disease in the subacute or chronic, as well as the acute, form involves & diathesis which may be either congenital or acquired. Of the causes which give rise to the diathesis, when it is acquired, and those which, co-operating with the predisposition to the disease, determine its occurrence and render it persistent, we have no positive knowledge.

The diagnosis of subacute and chronic, articular rheumatism involves discrimination from chronic and rheumatic gout, the diagnostic characters of which will be considered in the next chapter. Subacute or chronic synovitis, not rheumatic, is to be excluded. The points to be considered in differentiating the latter from rheumatic arthritis are, for the most part, those which have been stated in connection with the diagnosis of acute articular rheumatism.

A variety of synovitis affecting the knee-joint, and sometimes other joints, occurs in connection with gonorrhoea, and has been called gonorrhœal rheumatism. This is one of the instances in which the term rheumatism is misapplied. Barwell and others consider this affection as belonging in the category of inflammation of joints dependent on purulent infection of the blood. The author just named applies to this pyæmic form of disease the name pyarthrosis. He attributes the pyæmia, in cases of so-called gonorrhoeal rheumatism, to inflammation of the prostatic veins. A similar affection of the knee and other joints sometimes occurs after childbed, in consequence of uterine phlebitis.

Another misapplication of the term rheumatism is when syphilitic perios titis is called syphilitic rheumatism. For the consideration of this affection the reader is referred to works treating of syphilis. It may be stated that periostitis presenting all the characters of the affection as one of the tertiary effects of the syphilitic virus is occasionally observed in persons who have not been affected with syphilis.

Subacute, articular rheumatism is not necessarily chronic. It may disappear within the limits of the duration of the acute form of the disease. The liability to endocarditis and pericarditis is much less than when the disease is acute, but these and other complications occur in a certain proportion of cases. The sources of danger are in the liability to cardiac disease and the tendency to become chronic. Chronic, articular rheumatism is not dangerous as regards an immediate tendency to a fatal termination. But in view of its continuance for an indefinite period or during life, and the permanent deformities to which it leads in some cases, it is to be considered as a disease of no small importance. The condition of patients in the cases in which it has led to lesions involving anchylosis, with wasting of the muscles, is hopeless as regards recovery from these effects of the disease, although the condition is not incompatible with comfortable general health and a long duration of life.

The treatment of subacute and chronic, articular rheumatism embraces the employment of alkalies, but not to the same extent as in the acute form of the disease. They should not be continued steadily for a long period, but intermitted from time to time. The Vichy water is an agreeable alkaline

remedy well suited to chronic cases. Alkalies are indicated only during the continuance of the arthritic inflammation; that is, they are not indicated by the effects remaining after the arthritic inflammation has ceased.

The preparations of guaiacum have long been considered useful in chronic rheumatism. Their value in certain cases is abundantly established by clinical experience. Either the simple tincture, the ammoniated tincture, the mixture, or the compound decoction of sarsaparilla, into which guaiacum enters, may be employed. The bichloride or the iodide of mercury is strongly advocated by Barwell, and in conjunction, inunction with the mercurial ointment over the affected joint or joints until the gums are slightly touched. Mercurial baths and fumigations are recommended by Récamier and Trousseau. The iodide of potassium is sometimes highly useful. Colchicum exerts a good effect in some cases, given in small or moderate doses. Fuller regards the hydrochlorate of ammonia as "a remedy of singular efficacy," given in doses of from fifteen to twenty grains, in combination with bark. The same author has found, in some cases, arsenic serviceable. salts of quinia are not infrequently useful. Sulphur is another useful remedy. All these remedies are supposed to exert, in some way, a modifying, if not a curative, influence upon the disease The opportunity is often offered of making trial of them in succession in the same case.

The

The relief of pain, in certain cases, calls for opiates. They should be employed with as much reserve as is consistent with due regard to the object to be obtained. Aconite will sometimes fulfil the object, and, if so, is to be preferred.

The local treatment is important. Benefit may sometimes be obtained from small flying blisters or the application of the tincture of iodine. Methodic friction or shampooing, as described in connection with the local treatment of the acute form of the disease, conjoined with the use of stimulating embrocations, is often of much utility. Counter-irritation by "firing" has been recommended. Palliation of pain may frequently be procured by the application of the tincture of aconite or the veratria ointment. The local as well as general measures of treatment have reference to two objects, viz., the removal of, first, the inflammatory condition, and, second, the effects of the inflammation. In order to prevent stiffness and anchylosis, passive motion is advisable as soon as the inflammatory condition subsides.

External measures acting upon the entire surface are, perhaps, in certain cases, not less useful than internal remedies. Reference is had to the simple tepid bath, the alkaline bath, the Turkish bath, the sulphur vapor bath, and hydropathic packing. The resources of treatment should not be considered as exhausted without a fair trial of these measures.

Measures having reference to improvement of the general health and the invigoration of the system form an essential part of the treatment, embracing tonic remedies, with attention to diet, clothing, exercise, etc. It is unneces sary to go into details which are essentially the same in the treatment of most chronic affections. Change from a cold, changeable, and humid climate to one mild, uniform, and dry often proves the most effective measure which can be adopted. The mineral springs are frequently resorted to with advantage by persons suffering from chronic rheumatism. Of the different waters, the alkaline, sulphurous, saline, and chalybeate are each useful in certain. cases. Doubtless, however, much of the benefit derived from watering-places is due to the various incidental hygienic influences.

MUSCULAR RHEUMATISM.

The affection to be now noticed is one of the many to which the application of the term rheumatism is, to say the least, of doubtful correctness. There is very little ground for supposing that the essential pathological condition, or conditions, existing in the affections which have been considered in this chapter, obtain in so-called muscular rheumatism. This affection, so far as we can judge of its pathological character, is allied to neuralgia; it is probably a neuralgic affection, and, as such, may be properly called myalgia, and might with more intrinsic propriety have been considered under that head than in the present connection. I have placed it among the rheu matic affections, because it is, at the present time, and probably will continue to be, commonly known by the name muscular rheumatism. Being one of the neuroses, it has, of course, no anatomical characters. It is of frequent occurrence, both as an acute and chronic affection.

The symptomatic features of acute, muscular rheumatism are as follows: The development is usually gradual. A dull pain is at first felt in certain muscles, which increases, and, at length, becomes more or less severe. The pain is comparatively slight when the affected muscles are at rest. In certain positions the patient may be nearly or quite free from suffering, the constant pain which may be felt under these circumstances being of a contusive character, and spasmodic pains occurring from time to time; but in movements which involve contraction of the affected muscles, the pain is severe, cramp-like, and sometimes so excruciating that the patient can hardly repress loud groans or cries. Voluntary movements which occasion the severe pain are avoided as much as possible, but as it is impossible to maintain rigidly fixed positions of the body as a whole or of its different parts, the affected muscles are at times thrown into painful contraction, however much the patient may desire to avoid them. Movements occurring during sleep occasion the attacks of pain, and, hence, the patient is awakened at brief intervals. In some cases the affection changes its seat from certain muscles to others, but oftener it remains fixed in the muscles first affected.

The affected muscles are more or less tender on pressure, the tenderness being diffused over the whole of the space which the muscles occupy, not limited to certain points as in ordinary neuralgia. The tenderness is usually not great. Aside from the tenderness, there are no local characters, such as swelling, heat, or redness. The local phenomena are not those of inflammation, as in articular rheumatism. If the local symptoms denote inflammation of the muscles, the affection is not muscular rheumatism.

There is little or no constitutional disturbance beyond that occasioned by the suffering and loss of sleep. The appetite and digestion may not be impaired, and there is no febrile movement.

In the subacute or chronic form of the affection, pain similar to that which belongs to the acute form may be excited only when the affected muscles are contracted with unusual force; the patient experiences suffering when he makes certain violent movements. In other cases, pain is excited by particular movements when they are first made after a period of rest, and the pain shortly disappears if the movements be continued. The chronic, oftener than the acute affection is apt to shift its situation, affecting now certain muscles, and now those in another part. If the chronic affection remain fixed in particular muscles, they may become somewhat atrophied in consequence of their being kept as much as possible in a state of quietude.

The duration of acute, muscular rheumatism varies from a few hours to a week. Exceptionally the affection continues for several weeks. The dura

tion of the chronic form is indefinite. The course of the latter is usually marked by remissions or intermissions. In certain situations, viz., the loins, the walls of the chest, and muscles of the scapula, the chronic affection is apt to be long persisting.

The following are the principal situations of muscular rheumatism in the acute and chronic form as enumerated by Valleix :—'

1. The Muscles of the Head.-Situated in the occipito-frontal muscle, the affection is distinguished from neuralgia affecting the trifacial and occipital nerve, by the pain being referred to both sides of the head, by its being excited by movements of the muscle, and comparatively slight so long as the muscle is at rest, and by the absence of tenderness in disseminated points. The muscles of the eye are sometimes the seat. Movements of the eye then occasion more or less severe pain. The temporal and masseter muscle may be affected, causing pain in mastication.

2. The Muscles of the Neck.-In this situation the affection, as it commonly occurs, is known by the significant name torticollis. This name is applied to the affection when situated in the muscles of the antero-lateral aspect of the neck. The muscles on the posterior part of the neck are sometimes the seat of the affection. Valleix applies to the affection in the latter situation the name cervicodynia. In this situation the affection is to be distinguished from ordinary occipital neuralgia.

3. The Muscles of the Back.-Valleix calls the affection in this situation dorsodynia. Seated in these muscles, the pain is caused especially by movements which approximate the scapulæ.

4. The Muscle of the Loins.In this situation the affection is commonly known as lumbago. Valleix designates it lumbodynia. This is a frequent seat of the affection in a chronic form. It is to be discriminated from lumbar abscess, lumbo-abdominal neuralgia, and the pains incident to aneurism of the descending aorta.

5. The Thoracic Muscles.-Here the affection goes by the name pleurodynia. In making the diagnosis, pleuritis and intercostal neuralgia are to be excluded. This may easily be done by ascertaining the absence of the diagnostic characters of the two latter affections. The pain excited by forced breathing, coughing, and sneezing is not unlike that in pleuritis and intercostal neuralgia. In this situation the pectoral and intercostal muscles are affected.

6 Muscles of the Shoulder.-Valleix entitles the affection here situated scapulodynia. It is seated especially in the deltoid muscle, and it is liable to be confounded with arthritis situated in the shoulder-joint.

7. The Muscles of the Extremities.-Seated in the extremities, the affection is to be discriminated from neuralgia affecting the nervous trunks, and from the affection commonly known as syphilitic rheumatism.

8. The Abdominal Muscles.-The pain and soreness caused by the affection in this situation may suggest as probable or possible the existence of peritonitis. This disease is to be excluded by the absence of the general symptoms, and by firm pressure with the palm of the hand being well borne, as in cases of dermalgia.

9. The Visceral Muscular Structures.-The tongue, muscles of the pharynx and œsophagus may be the seat of muscular rheumatism, giving rise to pain in speaking and in deglutition. Examples, however, are extremely rare. Seated in the stomach, intestines, and uterus, as it probably may be, to distinguish the affection from visceral neuralgias is impossible, and in fact to consider it as distinct from the latter is to make a distinction without any

1 Guide du Médecin Praticien. Tome i.

essential difference. There is reason to believe that the diaphragm may be the seat of muscular rheumatism. It is, perhaps, more reasonable to consider this as the affection, rather than diaphragmatic pleuritis, in certain cases characterized by the instinctive arrest of diaphragmatic movements in consequence of pain, and by the intense suffering caused by coughing and sneezing, febrile movement and pleuritic effusion being wanting. It may be doubted if the affection be ever seated in the muscular walls of the heart.

In all these situations the most marked diagnostic feature of muscular rheumatism is the connection of cramp-like pain more or less severe, with the movements which bring into play certain muscles in the parts to which the pain is referred, pain irrespective of contractions of the affected muscles being comparatively slight and sometimes wanting. This diagnostic feature distinguishes muscular rheumatism, or myalgia, from neuralgic affections seated in the different nervous trunks. Another diagnostic feature is the diffusion of soreness over the affected muscles, whereas, neuralgia, seated in nervous trunks, is characterized by tenderness in circumscribed points. Inflammation affecting muscles is distinguished from muscular rheumatism by the constancy of pain or the absence of the remissions or intermissions which belong to the latter affection, by the existence of swelling and sometimes redness, by the greater degree of tenderness on pressure, and by the presence of more or less symptomatic fever.

The treatment of the acute form of the affection consists of sinapisms, followed by soothing, emollient applications over the affected muscles, rest, in the position most favorable to avoid contractions of the affected muscles, and the employment of anodynes either internally or by hypodermic injec tion. In the chronic form, small blisters in succession are useful, but not to the same degree as in cases of ordinary neuralgia. Friction or shampooing, either dry or with stimulating and anodyne liniments, affords relief and promotes a cure. "Firing" is recommended. The hydropathic treatment is said to prove successful in some obstinate cases, water being employed locally and generally. The salts of quinia, in full doses, are sometimes efficacious, especially when the affection is intermittent. Measures to invigorate the general health are important in chronic cases.

Persons prone to this affection are apt to have an attack after exposure of a portion of the body to a current of air, especially during sleep, or when the body is perspiring. The susceptibility to this cause of disease is to be overcome by the daily use of the sponge bath, by avoiding an over-abundance of clothing, and by becoming habituated to out-door exercise in all kinds of weather.

CHAPTER XI.

Gout-Anatomical Characters-Clinical History-Pathological Character-Causation-Diag

nosis-Prognosis-Treatment-Rheumatic Gout.

THE disease called gout is closely allied to articular rheumatism, and the two affections have been considered by some to be identical. As will be seen, however, they are shown to be essentially distinct forms of disease by points of contrast pertaining to morbid anatomy, clinical history, pathological character, and causation. They are kindred diseases in the same sense as the different eruptive fevers, or typhus and typhoid fever, are related to