As regards the relative power of the salicylates and of full alkaline treatment in protecting the heart, the following analysis and calculation deserve attention. The percentage of cases in which cardiac disease set in after the salicylate treatment began was, according to Powell, 18.75; according to Haviland Hall, 37.1; according to Finlay and Lucas, 11.60; Southey, 8; Brown, 4.76; Jacobi, 3.35, or a general average of 14 per cent.; whereas cardiac disease developed after the alkaline treatment had commenced in 13.6 per centum according to Blake;¹⁸⁵ in 10.7 per cent. according to Dickinson;¹⁸⁶ in 7 per cent. according to Owen; in 6.6 per cent. according to Finlay and Lucas; and in 2 per cent. according to Fuller; making a general average of only 7.8 per cent.

¹⁸⁵ Med. and Surg. Reports of Boston City Hospital, 1st Series, 1870.

¹⁸⁶ This percentage is obtained by adding together all the cases treated by alkalies given by Dickinson in his IX., X., XI., and XII. tables. Their total was 65 cases in which the heart was affected seven times. In table IX. from drachm ii-iv of alkaline salts were given daily, and in table X. about drachm iij daily.—Lancet, i., 1869.

Judging from these statistics, it is not improbable that a combination of sodium salicylate, with full doses of bicarbonate of sodium or chlorate of potassium, will give better results in the treatment of acute rheumatism than either of those classes of remedies singly. Indeed, Flint and others have advised such combinations, and Bedford Fenwick has recently stated, as a result of his experience in 30 cases, that if, after giving a free purge, followed by scruple doses of sodium salicylate hourly for six hours, that salt be stopped, and in twelve hours afterward half-drachm doses of citrate of potassium be administered every four or six hours until the saliva becomes alkaline, relapses will be extremely rare, and that this is the safest and most successful method of treating acute and subacute articular rheumatism.¹⁸⁷

¹⁸⁷ Lancet, i., 1882.

Having spoken somewhat fully upon the remedies of which I have most personal experience, and which have the largest number of advocates at the present time, and having advised the combination of these remedies, I shall only glance at some of the other remedies or methods of treating the disease still more or less employed.

Quinia, given in divided doses to the extent of 15 to 30 grains in the day, is still highly thought of in France in the early stages, during the course of and on the occurrence of relapses, in acute (especially febrile poly-) articular rheumatism. It is claimed by Briquet, Monneret,¹⁸⁸ Legroux, and others that although not a specific for the disease it moderates the general disturbance, diminishes the local affections, and even retards the development or lessens the gravity of the cerebral symptoms—that, although it does not control the cardiac inflammations, it is not contraindicated by them. The only recent English authority who has strongly advocated full doses of quinia in this disease is Garrod,¹⁸⁹ but he mixed the drug, in five-grain doses, with half a drachm of bicarbonate of potassium, a little mucilage, and spirits of chloroform, and gave it every four hours until the fever and articular affection had completely abated. Sufficient facts have not been published to permit of the formation of a reliable judgment as to the actual or the comparative value of either the simple quinia or the quino-alkaline treatment of acute and subacute articular rheumatism. There can be no doubt as to the value of quinia to meet certain conditions incident to the disease, such as debility, lingering convalescence, periodical relapse, excessive perspiration, failure of appetite, and perhaps, in some instances, high temperature. Barclay has found quinia of much service when depression has followed the long continuance of the alkaline treatment and is attended with alkaline urine and a deposit of the earthy phosphates.¹⁹⁰ It may be given by the rectum if not tolerated by the stomach or if the alkalines are being taken.

¹⁸⁸ La Goutte et le Rheumatisme, Paris, 1857.

¹⁸⁹ Reynolds's Syst. Med., 1870, p. 951.

¹⁹⁰ St. George's Hospital Reports, vol. vi. p. 111 et seq.

Greenhow¹⁹¹ has treated 43 cases with iodide of potassium and quinine, and says that his experience of this method contrasts favorably with that of salicine and salicylate of soda. However, pneumonia supervened in 3 cases while under treatment; cardiac inflammation arose in 6 cases (= 14 per cent.) after admission; single relapses of short duration occurred in 21 per cent.; and, excluding two cases in which the treatment was soon discontinued and 7 very mild cases, the remaining 34 cases were on the average each thirty-six days in hospital. Under this method relapses were less frequent (21 per cent. instead of 26 per cent.), and stay in hospital longer (36 instead of 30.4 days), than under that by the salicylates; but the number of cases treated is too small to base a final opinion upon. He prescribed 5 grains each of iodide of potassium and carbonate of ammonia three or four times a day, and 2 grains of quinia with three of extract of hyoscyamus in pill as often. This method, in principle at least, resembles that recommended by DaCosta, who administers in uncomplicated cases bromide of ammonium in 15- to 20-grain doses every three hours, and as soon as the acute symptoms have disappeared follows it by quinia in fair doses. It has not come into general use in this country, although its eminent proposer published his cases in 1869.¹⁹²

¹⁹¹ The Lancet, i., 1882, 913.

¹⁹² Pennsylvania Hospital Reports, vol. ii., 1869; New York Medical Record, September, 1874, p. 481.

Notwithstanding the encomiums passed upon propylamine—or, more correctly, trimethylamine—as a remedy for acute and chronic rheumatism by Awenarius of St. Petersburg in 1856, by Gaston of Indiana in 1872, by Dujardin-Beaumetz in 1873, and Peltier in 1874 (both of France), and Spencer of England in 1875, it has not been much employed, especially since the salicylates have attracted attention. It appears that in a considerable proportion of cases the articular pains have subsided in two or three days under its employment, and then the temperature has declined, but the visceral complications have not been prevented. From 4 to 8 minims of trimethylamine in an ounce of peppermint-water, with a drachm of syrup of ginger, may be given every hour or two, the intervals to be increased as the pains diminish. When pain has quite ceased the drug may be stopped and quinia given its place. It merits further study in this disease,¹⁹³ and Dr. Shapter of the Exeter Hospital has very recently stated that he is so convinced or the value of propylamine that salicylic acid has not fully commended itself¹⁹⁴ to him. Senator has recently recommended benzoic acid or its sodium salt in large doses (about ounce ss in the day) in those cases of acute rheumatic arthritis in which the salicylates have failed, although he admits that it scarcely rivals them.¹⁹⁵ His 22 patients were relieved in 4.4 days as the average, and no complications occurred in any of them. Benzoic acid is said not to produce the nausea, depression, or unpleasant head phenomena of salicylic acid, to which it is closely related in chemical composition.

¹⁹³ On this subject see Farier-Lagrange's Essai sur la Trimethylamine, Strasbourg, 1870; Journal de Méd. et de Chirurgie, 1873, No. 2; Medico-Chir. Rev., i., 1873, 497; Lancet, ii., 1875, 675; The Practitioner, London, i., 1875; Le Progrès Médicale, Jan. 10, 1874; ibid., Aug. 9, 1879.

¹⁹⁴ The Brit. Med. Jour., 1881, p. 1012. See also Tyson, Philadelphia Med. Times, 1879, vol. x. 359.

¹⁹⁵ Centralb. f. d. Med. Wiss., 1st May, 1880, quoted in Practitioner, Sept., 1880. See also McEwan's experience, Brit. Med. Journ., i., 1881, 336; F. A. Flint, M.D., N.Y. Med. Gazette, 1880.

Space will not permit of any notice of lemon-juice, perchloride of iron, the mineral acids, or the blistering treatment. Of this last my experience enables me to say that it frequently relieves the pains promptly, but does not at all always protect the heart. In my opinion it deserves an extended employment in conjunction with early and full doses of the sodium salicylate. As Andrews has not by any communication made since the publication of his paper in 1874¹⁹⁶ maintained the value of the treatment of the disease by an exclusively non-nitrogenous diet of arrowroot, and as he had then treated but eight cases in that way, it is hardly necessary to consider it as a method of treatment.

¹⁹⁶ St. Barth. Hospital Reports, vol. x. 359.

Having spoken of the treatment of the general disease acute articular rheumatism, it remains to speak of the treatment of its visceral manifestations and of some of its more important incidental symptoms and complications. As the treatment of the various forms of cardiac inflammation will be given in extenso in the articles specially devoted to those topics, I will be very brief in my notice of them.

In every case of rheumatic fever it is our primary duty to employ those measures as early and deftly as possible which in the present state of knowledge appear to promptly relieve the pyrexia and articular symptoms, and lessen the tendency to, but do not altogether prevent, the visceral complications. Such measures have been already said to be the administration of the salicylates and alkaline salts together in full doses, and the observance of certain dietetic and hygienic details to be given hereafter. If, notwithstanding, peri- or endocarditis, or both, supervene, as it frequently happens, what is to be done? I reply that even in pericarditis active interference is seldom necessary; the general treatment previously employed may be continued in the hope that it may mitigate the cardiac inflammation by reducing the pyrexia and subduing the polyarthritis, even although it be incapable of directly controlling the pericardial inflammation. If the pain in pericarditis be really severe and the heart's action much disturbed, a dozen leeches may be applied over the heart, and be followed by anodyne fomentations or hot poultices applied, as Lauder Brunton advised, over several layers of flannel interposed between the skin and them. Leeching, however, is seldom needed, a hypodermic injection of morphia generally sufficing to relieve the pain. Should these measures not relieve the pain and allay the cardiac excitement, small and repeated doses of chloral, which Balfour observes "is not more useful as a sedative than as an antiphlogistic," may be given. If there be, as so frequently happens, but little pain or cardiac disturbance, there being only a friction sound revealing the inflammation, the hot poultices or anodyne fomentations, or even covering the front of the chest with wadding or a belladonna plaster, which I prefer, will suffice. Should pericardial effusion ensue, the diet must be improved, and if much debility exists, the salicylate and alkalies should be stopped, and wine may be given along with quinine alone or with pretty full doses of muriate of iron. As the strength returns absorption commonly takes place; but if it is delayed, either the iodide of potassium or the infusion of digitalis may be employed along with the quinia; or, if no special contraindication exist, a pill containing a grain each of blue mass, digitalis, squill, and quinia may be given three times a day and its effects carefully watched. Much difference of opinion obtains as to the value of flying blisters on the præcordia. Although not often required, they appear to be more useful than iodine applications. In those comparatively rare instances in which the effusion is abundant and remains unabsorbed, either because it is largely sero-purulent or purulent, it is proper to aspirate the pericardial sac, which should certainly be done if marked signs of cardiac oppression and failure coexist. Having once hesitated to aspirate in recent rheumatic pericarditis with copious effusion in a lad, and found a large amount of pus in the sac after death, I would warn against hesitancy under such circumstances. Careful employment of the instrument can hardly do harm if even no large amount of effusion exist.

Active treatment is quite uncalled for, as a rule, in acute rheumatic endocarditis unattended by pericarditis. If the valvulitis occur notwithstanding the employment of the anti-rheumatic remedies, it is very doubtful if we have any others capable of directly controlling that inflammation. Inasmuch, however, as, owing to the inflamed surface being in constant contact with the fluid, many of our remedies may be applied directly to the diseased part, it is well neither to be dogmatic on the point nor to abandon hope that agents may yet be found that will prove directly useful. While carefully treating the rheumatic fever, the main indications remaining to be filled appear to be to quiet the cardiac excitement and secure as much rest to the inflamed valves as possible. The alkaline salts, salicine, and the salicylate of sodium do usually greatly reduce the frequency of the heart, and, pro tanto, secure rest. The tincture of aconite given hourly, so as to slacken the heart's speed, is useful in the sthenic stage of endo- and of pericarditis; and the benefit of absolute rest of the body in bed and of the joints in splints during the entire course of rheumatic fever, in preventing cardiac inflammations and in treating them, has been shown by Sibson.¹⁹⁷ When signs and symptoms of cardiac weakness arise, whether from the pressure of pericardial effusion or from myocarditis or any other cause, the employment of salicylates, alkalies, aconite, and chloral should be at once stopped and alcoholic stimulants and tonics (strychnia, quinia, iron) and good food should be freely administered. The most valuable point made of late in the therapeutics of acute inflammations of the valves is Fothergill's development of Sibson's principle—viz. that "general quietude for weeks after an attack of acute endocarditis is indicated," as the cell-growth in the valve may not be quite over in a less time,¹⁹⁸ and the work of repair, we may add, not completed. The same principle is specially applicable in myocarditis.

¹⁹⁷ Reynolds's System of Med., vol. iv. p. 527, Eng. ed.

¹⁹⁸ Diseases of Heart, with their Treatment, 2d Series, 1879, 149.

The disturbances of the nervous system were divided into those dependent upon gross organic alterations of the nervous centres and their envelopes, and those not so related, but which we commonly speak of as functional. Were it possible generally—which it is not—to diagnosticate rheumatic meningitis from the merely functional form of so-called cerebral rheumatism, then its treatment would resolve itself into a vigorous use of the anti-rheumatic remedies, salicylates, alkalies, etc., and the active employment of ice and leeches to the scalp, purgatives, full doses of the iodide and bromide of potassium, ergot, etc. If, together with the symptoms of that often obscure and comparatively rare complication of rheumatic fever, ulcerative endocarditis, there occurred severe headache, delirium, or paralysis, we might find great difficulty in determining the cause of the cerebral disturbance, and would naturally vary our measures according as we suspected meningitis, embolism, or simple functional disturbance, and the treatment adapted to these several conditions will be found under their respective heads in this work.

Coming now to the functional disturbances of the nervous centres, which are the ordinary forms met with in acute articular rheumatism, they may be divided, for therapeutical reasons, into two groups: (1) Those unattended by hyperpyrexia, and (2) those preceded, accompanied, or followed by hyperpyrexia.

(1) When any sign of disturbance of the nervous system, delirium, restlessness, taciturnity or talkativeness, insomnia or somnolence, deafness, tremulousness, vacancy, stupor, or what not, occurs in rheumatism with but a moderate temperature, 101° to 103°, while we anxiously watch the temperature from hour to hour, prepared to combat any tendency to hyperthermia the moment it is discovered, we endeavor to control the cerebral disturbance as in other febrile affections, but with greater diligence, knowing that in this disease these nervous symptoms very often precede hyperpyrexia. We persist with the salicylates to reduce the rheumatic element of the affection, employ remedies to control the cardiac or pulmonary inflammations which are so frequent in such circumstances, sustain the general powers by food, wine, and quinia, if, as frequently happens, there are evidences of failing strength, and meet any other special indication that may arise. For example, we procure sleep and allay motor and mental excitement by opium or chloral and by evaporating lotions or the ice-cap to the head. We reduce temperature, allay restlessness, preserve the strength, and promote sleep by lightening the bed-clothes, drying frequently the entire surface of the body if it is perspiring freely, or by sponging it with tepid water hourly if dry and hot. We act on the kidneys, bowels, and if necessary the skin, if from the scantiness of the urine or other evidence we suspect uræmia. Should these means fail and the delirium and other symptoms which occur in cerebral rheumatism continue, and especially should they be severe, it would be, in the writer's opinion, proper to employ the methods that are now resorted to when hyperpyrexia accompanies those symptoms; for patients suffering from cerebro-spinal disturbance or rheumatic fever, although unattended by hyperthermia, do die if those symptoms continue. Moreover, the hyperthermia may at any moment supervene; it is itself perhaps as much a nervous disturbance as delirium, and apt to succeed the latter. It was in these very cases in which the delirium preceded the hyperpyrexia that the London committee to be presently mentioned found the highest mortality. If along with these nervous symptoms the articular pain or the sweating disappear suddenly, or if the pulse suddenly increase in frequency without demonstrable increase of cardiac mischief, there is reason to anticipate the supervention of hyperpyrexia.

(2) When the cerebro-spinal disturbance of rheumatic fever is followed, preceded, or accompanied by hyperpyrexia, there is one indication for treatment which dominates all others, and that is the prompt reduction of the hyperthermia. The terrible danger of this condition in rheumatic fever is known to all persons who have had much experience of the disease. Wilson Fox in 1871 had not known a case recover after a temperature of 106° unless under the use of cold, yet that is not an alarming temperature in intermittent or relapsing fever, and is often recovered from in typhoid fever. Thanks to Wilson Fox,¹⁹⁹ Meding,²⁰⁰ H. Thompson,²⁰¹ H. Weber,²⁰² I. Andrew,²⁰³ Maurice Raynaud,²⁰⁴ Black,²⁰⁵ Fereol,²⁰⁶ and many others since, it has been established that when the hyperthermia is removed by external cold the nervous disturbances also usually at once disappear or lessen very much. And thus we are brought to the treatment of the hyperpyrexia of acute articular rheumatism. On this important topic it will be most satisfactory and convincing to give some of the conclusions arrived at respecting hyperpyrexia in acute rheumatism by a committee of the Clinical Society of London.²⁰⁷ I will condense some of them.

¹⁹⁹ Treatment of Hyperpyrexia, 1871, and Lancet, ii., 1871.

²⁰⁰ Archiv für Heilkunde, 1870, xi. 467.

²⁰¹ Brit. Med. Jour., ii., 1872; Lancet, ii., 1872; and Clinical Lectures, 1880.

²⁰² Clin. Soc. Transactions, v. 136.

²⁰³ St. Bartholomew's Hosp. Repts., x. 337.

²⁰⁴ Journal de Thérap., No. 22, 1874.

²⁰⁵ Gaz. Hebdomad. de Méd. Sci., 1875.

²⁰⁶ Soc. Méd. des Hôpitaux, 8 Juin, 1877.

²⁰⁷ Brit. Med. Jour., i. 82, 807.

1. "Cases of hyperpyrexia in acute rheumatism prevail at certain periods;" "such excess corresponds in a certain degree, but not in actual proportion, to a similar excessive prevalence of acute rheumatism generally. The largest number of cases of hyperpyrexia arise in the spring and summer months, whereas rheumatism is relatively more common in the autumn and winter." 2. "Whilst very little difference obtains between the two sexes in regard to proclivity to rheumatism, the proportion of males to females exhibiting hyperpyrexial manifestations is 1.8 to 1." (3 omitted.) 4. "The cases of hyperpyrexia preponderate in first attacks of rheumatic fever." 5. "Hyperpyrexia is not necessarily accompanied by any visceral complications, but may itself be fatal. The complications with which it is most frequently associated are pericarditis and pneumonia." 6. "The mortality of these cases is very considerable, hyperpyrexia being one of the chief causes of death in acute rheumatism." 7. "Although present in a certain number of cases, and these of much value from their prodromal significance, neither the abrupt disappearance of articular affection, nor the similarly abrupt cessation of sweating, is an invariable antecedent of the hyperpyrexial outburst." (8, 9, 10 omitted.) 11. "The post-mortem examinations in a certain proportion elicited no distinct visceral lesions, and when present the lesions were not necessarily extensive." 12. "The prompt and early application of cold to the surface is a most valuable mode of treatment of hyperpyrexia. The chances of its efficacy are greater the earlier it is had recourse to. The temperature cannot safely be allowed to rise above 105° F. Failing the most certain measure—viz. the cold bath—cold may be applied in various ways: by the application of ice, by cold affusions, ice-bags, wet sheets, and iced injections."

Whatever differences of opinion may obtain as to the value of cold in the treatment of the hyperthermia of typhoid fever, there is a tolerable consensus of opinion that it is our most reliable and promptest resource in those formidable cases of rheumatic fever attended with hyperpyrexia, both when alarming delirium and coma coexist and when they are absent.²⁰⁸ Space will not allow of details here in the employment of cold to reduce hyperpyrexia—a subject discussed elsewhere in this work. Suffice it to say, that besides the cold bath (70° or 60°) which the committee regards as the most certain, the tepid bath (96° to 86°) is employed by Fox and regarded as the best by Andrews; it may be cooled down to 70° by adding ice or cold water to it (Ziemssen). The cold wet sheet-pack is still thought much of, like the last, in old and feeble people. Kibbie's method deserves more attention than it has received. He pours tepid water (95° to 80°) over the patient's body, covered from the axillæ to the thighs with a wet sheet and laid upon a cot, through the open canvas of which the water passes and is caught on a rubber cloth beneath the cot, and conveyed into a bucket at the foot of the bed.

²⁰⁸ The powerful depressing effects of high temperature on the human body, and the remarkable opposite influences of a cool temperature, have been personally experienced by the writer in the last three days. For two or three days the weather has been very hot, and he has experienced the usual feeling of exhaustion, incapacity for thought and action. After a thunderstorm last evening the temperature fell 25°, and this morning, twelve hours later, he feels vigorous, refreshed, and capable of intellectual and physical labor. The change is remarkable.

The existence of polyarthritis, of peri- or endocarditis, of pneumonia or pleurisy, does not contraindicate the cold bathing. If much weakness of the heart obtains, it is well to give some wine or brandy before employing the bath, and perhaps while in it, and the patient should not be kept in the bath until the temperature reaches the norm, for it continues to fall for some time after his removal from the bath. If the temperature fall rapidly 2° to 3° in five or six minutes, remove the patient from it as soon as the temperature recedes to 102° or 101° F. If it fall very slowly, the bath may be continued till the temperature declines to 99.5°, when he should be taken out. Should marked symptoms of exhaustion or of cyanosis arise, the bathing should be at once stopped. After it has been found necessary to employ cold in this way, the thermometer should be used every hour, and if the temperature tend to rise rapidly again, the diligent application of a succession of towels wrung out of iced water and applied to the body and limbs, or of Kibbie's method, may suffice; but should they not, and a temperature of 103° or 104° be rapidly attained again, the cold or tepid bath should be at once resumed. In severe cases of this kind a liberal administration of alcohol and liquid food is generally needed, and it is well to try antipyretic doses of quinia by mouth or rectum, although they are usually very disappointing in these cases. It is admitted that cold baths have in a few rare instances caused congestion of the mucous membrane, pneumonia, pleurisy, and even fatal syncope. This is a reason for the exercise of care and constant oversight on the part of the physician, but hardly an excuse for permitting a person to die in rheumatic hyperpyrexia without affording him at least the chance of recovery by the use of the cold or tepid bath.

If delirium and deafness supervene during the employment of the salicylates, it is prudent to suspend their use and take the temperature every couple of hours, as one cannot feel confident that hyperpyrexia may not be impending. Both Caton and Carter have found that the addition of bromohydric acid to the sodium salicylate mitigated or controlled the tinnitus and deafness produced by full doses of that salt.

SUMMARY OF TREATMENT OF ACUTE RHEUMATIC POLYARTHRITIS.—As a general rule, commence at once with a combination of sodium salicylate, say 10 grains, and citrate of potass. gr. xv, every hour for twelve doses, after which give the citrate alone every two hours during the rest of the day. Repeat these medicines in the same way daily until the temperature and pain have subsided, when only half the above quantities of the drugs are to be given every twenty-four hours for about a week longer, after which three 15-gr. doses of the salicylate, with a like quantity of the citrate, are to be administered every day for another week or ten days, to prevent relapses. It is in this third week that quinia is most likely to be required, and as a general rule it may be given with benefit at this period in doses of 2 grains three times a day between the doses of the salicylate. Should the above dose of salicylate not relieve the pains sensibly in twenty-four hours, increase next day the hourly dose to 15 or 20 grains; and if this free administration of the medicine afford no relief after four or five days' use, substitute for the salicylate salt the benzoate of ammonia in 15- to 20-grain doses hourly, continuing the citrate of potassium and conducting the treatment in the manner first advised. Should the benzoate likewise fail after four or five days' trial, omit it, and employ the full alkaline method together with the quinia, of which about 10 to 15 grains may be given in the day between the doses of the alkaline salt.

For the local treatment no uniform method is invariably applicable. In many cases simply painting the joints with iodine daily, or enveloping them in cotton wool, with or without the addition of belladonna or laudanum, and securing it by the smooth and gentle pressure of a flannel roller, proves sufficient. Hot linseed poultices containing a teaspoonful of nitre or of carbonate of soda often afford relief, and so does Fuller's lotion, applied to the articulations by means of spongio-piline, or lint covered with oiled silk. It consists of liq. opii. sed. fl. ounce j, potass. carb. drachm iv to drachm vj, glycerinum fl. ounce ij, aqua fl. ounce ix. It must be plentifully applied. If the articular affection be very severe and not relieved by the above measures, absolute immobility of the joints, secured by means of starch and plaster-of-Paris bandages, has been shown to be very useful, relieving the pain, shortening the duration of the local and the general disturbance, and protecting neighboring joints from invasion.²⁰⁹

²⁰⁹ See Heubner in Archiv der Heilkunde, vol. xii., and Oehme in ibid., vol. xiv., and a striking case in St. Barth. Hosp. Reports, 1876, p. 174, by R. Bridges, M.D.

We have little experience in this country of ice continuously applied to the joints until all the symptoms of acute rheumatism have disappeared (Esmarch and Stromeyer).

Circlets of blistering fluid applied above all the affected joints simultaneously, as practised especially by Herbert Davies,²¹⁰ often afford prompt relief to the pain, but they do not invariably protect the heart, in my experience.

²¹⁰ London Hospital Reports, vol. i., 1864, 292.

The hygienic and dietetic management of acute articular rheumatism demands careful attention. While the room should be well supplied with fresh air and sunlight, it should be kept at a uniform temperature and free from draughts. Feather and other very soft beds should be prohibited. Many authorities put the patient between heavy blankets, which I regard as a mistake. The bed-clothing should be light and just sufficient to keep the patient agreeably warm; the night-gown may be of thin flannel and the sheets of cotton. The excess of perspiration should be removed by gentle rubbing with a warm towel at regular intervals, and the sheets should be changed frequently before they become almost saturated with the perspiration. Fatigue and exposure of the patient's person when taking food, attending to his natural calls, or having his personal or bed-clothing changed should be specially guarded against.

The diet in the early actively febrile stage should consist of panada, corn-meal or oat-meal gruel, milk, and barley-water, or even pure milk. Where persons will not take milk the various thin animal broths to which good barley-water or arrowroot or well-boiled rice has been added, jellies, sago and other starchy puddings, may be allowed. Suitable drinks are—plain water, Seltzer and Apollinaris water, carbonic-acid water, lemonade. This low, unstimulating diet should be observed until all fever and articular inflammation have subsided, the tongue become clean, and the visceral inflammations declined, and a return to solid food, and especially to animal food, should be made cautiously. Eggs are to be regarded as of very doubtful safety in this disease. As a very general rule, ales, wines, and the stronger alcoholic liquids are objectionable, but they may be required under the same conditions as in other fevers. Should the salicylates depress the heart, old wine or whiskey may be given with advantage.

During convalescence the patient should not be permitted to leave his bed for several days after complete removal of the fever and articular pain, and for the first four days he should occupy a sofa or easy-chair. Premature walking may induce relapse. An occasional alkaline or sulphur bath, if cautiously taken, sometimes appears to complete the recovery. If endocarditis have existed, a longer rest is desirable, more especially in severe cases, in order that the reparative process going on in the lately inflamed valves may not be in the least disturbed.

Chronic Articular Rheumatism,

synonymous with rheumarthritis chronica, rheumatisme articulaire chronique simple (Besnier), polyarthritis synovialis chronica (Heuter), is defined here as a chronic idiopathic inflammation of one or a few articulations, which is more prone to become fixed than the acute form, and which, notwithstanding its protracted duration, produces no profound structural alterations in the joints.

ETIOLOGY.—It may be the direct sequel of a single attack or more commonly of several attacks, of acute, or more especially of subacute, articular rheumatism. But it is generally a primary affection, occurring in persons who have not had either acute or subacute rheumarthritis, yet owning the same causation as these, and occasionally in its course exhibiting acute or subacute symptoms. The specially predisposing conditions are inheritance; repeated attacks of subacute or acute articular rheumatism, which in accordance with general laws impair the resisting power of the affected joints; prolonged residence or employment in cold, damp, or wet rooms or localities; repeated exposure to bleak, cold currents of air or to frequent wettings of the body or lower limbs. For these reasons it is most common amongst the poor, who are especially exposed to the influences just mentioned; and amongst them cellar-men and sailors, washerwomen and maid-servants, are very liable to the disease. It is chiefly an affection of advanced life, or at least of mid-age, and is rare in youth. The first attacks, and especially exacerbations, are apt to be induced by the direct action of a draught of cold air or by unusual exposure to cold and damp air, especially when the body has been fatigued or overheated. In many cases no distinct exciting cause can be traced.

The morbid anatomy of simple chronic articular rheumatism will vary with the severity and duration of the disease. The alterations are such as chronic inflammation of a non-suppurative character might be expected to produce in the joints by one who had learned those characteristic of acute rheumarthritis. In the simple chronic form the proliferating process involves chiefly the synovial membrane, the capsular and other ligaments, and the periarticular tissues; to a less degree the cartilages, and to a much less degree, and exceptionally, the osseous surfaces. The synovial membrane is thickened, slightly injected, and its fringes hypertrophied and more vascular than normally. Little fluid usually exists in the joint unless during an exacerbation, when a moderate amount of thin, cloudy serum may be present; generally only a trace of thick, turbid fluid, containing oil-globules, and in severe cases débris of the cartilages, but no pus, is found. The fibrous capsule and ligaments become thickened, dense, and stiffened by hyperplasia; and sometimes the adjacent tendons and their sheaths, the fasciæ and aponeuroses, undergo similar alterations, so that the movements of the joints become seriously interfered with. In some cases this irritative hyperplasia specially involves these periarticular fibrous structures, and these, undergoing retraction, produce marked deviations, subluxations, and deformities of the articulations very like those observed in rheumatoid arthritis, although the osseous components of the joints are unaffected. Jaccoud gave to such cases the title of chronic fibrous rheumatism.²¹¹ It is worth noting that Jaccoud's, Charcot's,²¹² and Rinquet's²¹³ cases of so-called "chronic fibrous rheumatism" developed out of acute articular rheumatism, while Besnier's was primarily chronic. In simple chronic rheumatism, if protracted, the cartilages also proliferate, lose their semi-transparency and polish, and become opaque and white; they are often rough and traversed by fissures, and occasionally present erosions; and these erosions are either naked or covered with a layer of newly-formed connective tissue, which may occasionally produce fibrous adhesions between the articular surfaces. Points of calcification occur in the cartilages and tendons in very chronic cases. Instances are observed in which the bones exhibit, to a slight degree, the alterations found in rheumatoid arthritis, and are probably transitional between the two affections. The muscles which move the affected articulations in severe cases are often atrophied, and the wasting imparts to the joints an appearance of considerable enlargement.

²¹¹ Vide Jaccoud, Clin. Méd. de la Charité, 23e Leçon, Paris, 1867.

²¹² Besnier, Dictionnaire Encyclopéd., etc., t. iv., p. 680 et seq.

²¹³ Du Rheum. Artic. Chronique, etc., par Martial Rinquet, Thèse, Paris, 1879, pp. 28-33.

SYMPTOMS AND COURSE.—Simple chronic articular rheumatism presents many varieties. In the milder forms the patient experiences trifling or severe pain in one, or less frequently in two or more, joints, more especially in the knee or shoulder, or both, attended with want of power in the member or with stiffness in the affected articulation. The pain frequently is likewise felt in the soft parts, muscular and tendinous, near the joints, and is usually increased by active or passive movement; it is not always accompanied by tenderness, and rarely with local elevation of temperature or swelling. The wearying aching in the joint is of an abiding character, but is very liable to exacerbations, especially at night; and these come on just before atmospheric changes, such as a considerable fall of temperature, the approach of rain, variations in the direction of the wind, etc., and they usually continue as long as the weather remains cold and wet. A very common symptom is a creaking or a grating which may be felt and heard during the movements of the joint.

The above symptoms may rarely prove more or less constant by night and day for years, but far more frequently, at least at first, they last an indefinite period and disappear to recur again and again, especially in the cold and changeable seasons of the year. Although in the earlier attacks, and often for a long time, no alteration of structure is perceptible in the painful joints, yet in some instances slight effusion into the articulation may be observed during the exacerbations, or the capsule and ligaments may at length become slightly thickened, or the muscles may waste and produce an apparent enlargement of the joint; and this prominence of the articular surfaces may be increased by retraction of the tendons and aponeuroses—a condition which causes real deformities (deviations, subluxations, etc.) of the articulation and impairs more or less its movements. In very chronic cases a fibrous ankylosis may be established.

These last-mentioned conditions often entail great and long-continued suffering, and may even cause some anæmia and general debility; but very frequently the general health and vigor continue good, notwithstanding the permanent impairment of the functions of one or several of the large articulations, and the liability to exacerbations often amounting to attacks of subacute rheumarthritis from changes in the weather, fatigue, or exposure.

Besides the above varieties may be mentioned a not infrequent one consisting of a series of attacks of subacute articular rheumatism recurring at short intervals, involving the same joints, and attended with slight elevation of temperature, febrile urine, perspiration, and moderate local evidences of synovitis, heat, pain, tenderness, swelling, and effusion into the affected joints. This is an obstinate variety, and is often associated with rheumatic pain in the muscles and fibrous tissues of the affected member.

Simple chronic articular rheumatism, like the acute form, is most apt to affect the larger articulations, knees, shoulders, etc., but it frequently also involves the smaller ones of the hands and feet. Although usually polyarticular, it is prone to become fixed in a single joint, but even then it may attack several other articulations, and may migrate from one to another without damaging any.

The course of the disease is usually one of deterioration during persistent or recurring attacks, and in many cases the intervals of relief become shorter and less marked; the joints become weaker and stiffer; and although the pain may not increase and the general health may not be seriously impaired, yet the patients may continue for many years or the rest of their lives severe sufferers, unable to work, and often hardly able to walk even with the aid of a stick. Occasionally, after several years of pain and weakness, a sudden or slow improvement may set in and the patient become free from pain and lameness, and only experience some stiffness in the movements of the joints after several hours of rest, and slight thickening of the ligaments and capsule of one or more articulations. The duration of the disease is indefinite; the danger to life trifling.

The complications of simple chronic articular rheumatism are held by many, and especially by those who regard the disease as constitutional or diathetic, to be the same as those of the acute form, and that they may precede, follow, alternate, or occur simultaneously with the articular affection. All admit that they are observed much less frequently in the former than in the latter. Other pathologists either deny the occurrence of the visceral complications (Senator, Flint) or do not mention them (Niemeyer). It is not denied that cardiac disease may be found in chronic articular rheumatism which has succeeded the acute form, and which may then be referred to the acute attack. The tissue-changes then set up may not have produced at the time the murmurs indicative of endocarditis, but these tissue-changes may have ultimately roughened the endocardium, puckered a valve, or shortened its cords, so that cases of chronic articular rheumatism having a history of an acute attack cannot be safely included when inquiring into the influence of the chronic form upon the heart or other internal organ. Attention has not been sufficiently given to ascertain the frequency of the occurrence of these complications in primary chronic articular rheumatism, and reliable evidence is not at hand. It is not unlikely that the chronic form may slowly develop cardiac changes, as the acute form rapidly does; but when the advanced age of the persons most liable to chronic rheumatism is borne in mind, it must be admitted that valvular and arterial lesions (endarteritis) are observed at such periods of life independently of rheumatism, and referable to such causes as repeated muscular effort, strain, chronic Bright's disease, senile degeneration, etc. Somewhat similar observations are applicable to the attacks of asthma, of subacute bronchitis, of neuralgia, and of dyspepsia, which are frequently complained of by sufferers from simple chronic rheumarthritis. Such affections are common in elderly people in cold and damp climates; they may be mere complications rather than manifestations of rheumatism, or outcomes of the confinement and its attendant evils incident to chronic articular rheumatism, as is probably the relationship of the dyspepsia. There is no doubt of the frequent coexistence of muscular rheumatism with this variety.

DIAGNOSIS.—Simple chronic articular rheumatism may be confounded with rheumatoid arthritis, with the articular affections of locomotor ataxia and other spinal diseases, with chronic articular gout, with syphilitic and with strumous disease of the joints. The reader may consult the observations made on four of these affections in connection with the diagnosis of rheumatoid arthritis. A few additional remarks are called for in distinguishing chronic articular rheumatism from chronic articular gout, which is often a very difficult problem. Both are apt to be asymmetrical in distribution, to have paroxysmal exacerbations, to recur frequently without damaging the articulations, to have been preceded by acute attacks of their respective affections, and to be uncomplicated by endo- or pericarditis. But chronic rheumarthritis has no special tendency to attack the great toe; it is more persistent than gouty arthritis; it does not, even when of long standing, produce the peculiar deformities of the articulations or the visible chalk-like deposits in the ears or fingers observed in chronic gout. The etiology of the two diseases is dissimilar. There is no special liability to interstitial nephritis in articular rheumatism, nor is urate of soda present in the blood in that disease.

In chronic strumous or tubercular disease of a joint the youth, the personal and family history, and sometimes the evident defective nutrition, of the patient; the moderate degree of local pain compared with the considerable progressive and uniform enlargement of the joint; the evident marked thickening of the synovial membrane, either early or late according as the disease has originated in the synovial membrane or in the bones; the continuous course, without marked remissions or exacerbations, of the disease; the rarity with which more than one joint is affected; and the tendency to suppuration, ulceration, marked deformity, and final destruction of the joint,—will prevent the disease from being mistaken for chronic rheumatism.

The PROGNOSIS in simple chronic rheumarthritis is unfavorable as regards complete recovery, and it is chiefly while comparatively recent, and when the sufferer can be removed from the conditions productive of the disease, that permanent improvement, and sometimes cure, may be expected. As a rule, the disease once established recurs. It does not, however, endanger life.

TREATMENT.—All are agreed that hygienic treatment constitutes an essential, if not the most valuable, part of the curative and palliative management of chronic rheumarthritis. A dry and uniform climate is the most suitable, and there is much evidence in favor of a dry and warm rather than a dry and cold climate. Protection of the body against cold and damp by means of flannel next the skin, sufficient clothing, residence in dry and warm houses, etc., is of prime importance. In fact, all the known or suspected causes of the disease should be as far as possible removed.

The direct treatment of the disease resolves itself into general and local, and is essentially the same as that recommended for rheumatoid arthritis, to which subject the reader is referred. A few observations only need be made here. Although, like everything else in chronic rheumarthritis, it often fails, no single remedy has in the writer's experience afforded so much relief to the pain and stiffness of the joints as the sodium salicylate; and he cites with pleasure the confirmatory testimony of J. T. Eskridge of Philadelphia,²¹⁴ of whose 28 cases 75 per cent. were decidedly benefited. Jacob of Leeds also reports some benefit in 75 per cent. out of 87 cases treated by the same agent.²¹⁵ It must be given in full doses, and be persevered with. Salicylate of quinia should be tried if there be much debility or if the sodium salt fail. Propylamine or trimethylamine is deserving of further trial in this disease. From 100 to 200 grains are given in the day in peppermint-water. Iodide of potassium, cod-liver oil, arsenic, iodide of iron, and quinia are all and several remedies from which more or less benefit is derived in chronic articular rheumatism. The combination of iodide of potassium with guiaiac resin—gr. ij-iij of each three times a day in syrup and cinnamon-water—is sometimes very useful. The writer has no experience of the bromide of lithium (Bartholow). When the skin is habitually dry and harsh a dose of pilocarpine every other night for a few times will often prove very useful.

²¹⁴ Phila. Med. Times, vol. ix. pp. 75-77, 1878, and The Medical Bulletin, Phila., July, 1879, pp. 44-48.

²¹⁵ Brit. Med. Jour., ii., 1879, 171.

Cod-liver oil, iron, quinia, etc., the various forms of baths and mineral waters, electricity, and the several local measures recommended for the treatment of rheumatoid arthritis, are all occasionally very useful in, and constitute the appropriate treatment of, simple chronic articular rheumatism. The dietetic management of the two affections should be the same.