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COINCIDENCE OF RHEUMATIC ANDCARDIAC INFLAMMATION.

Noituelles Recherches sur le Rhumatisme Articu-laire Aigll in général, et specialemeitt sur laLoi de Coincidence de la Pericardite et de l’Eiidocardite avec cette Maladie, ainsi que surl’Efficacité de la Formule des Emission San-

guines Coup sur Coup dans son Traitement;Par J. BOUILLAUD, Professeur de CliniqueMédicale ala Faculte de Médicine de Paris.A Paris, chez J. B. Bailliere, &c. &c.

(New researches on acute articular rheumatismin general, and particularly on the law ofcoincidence of pericarditis and endo-carditiscoincidence of pericarditis and endo-carditisicith this disease, &c. c.)

The high character of M. Bouillaud as a

pathologist and an observer of disease, in-duces us to present our readers with ananalysis of his views on the nature andtreatment of rheumatism, as they are con-tained in this brochure, which, from the carewhich has been bestowed in collecting thefacts, the manner in which the materials arearranged, and the value of the whole as arecord, presents to practitioners a goodauthority for information and reference, andto authors an excellent example in their

literary labours. The occasional co-existenceof rheumatic and cardiac inflammation, or,more correctly speaking, the metastasis ofarticular inflammation to the heart and its

appendages, had been long since noticed byseveral medical writers. The object of thepresent work is to prove the almost constant

coincidence, either of endo-carditis, or of

pericarditis, or of endo-pericarditis, withacute articular rheumatism. As a long’ taskis before us, though one of a very usefuland interesting character, we shall, withoutfurther preamble, proceed to condense thecontents of the work.M. Bouillaud tells us that his discovery

of this important relation between articularand cardiac inflammation was in a manneraccidental. He happened to examine thesounds of the heart in some of his patientswho were either still labouring under, oralready convalescent from, acute articular

rheumatism, when, to his great surprise, heheard, a distinctly marked bruit de râpe, descie, or de soufflet, such as he had frequentlymet with in cases of chronic or organic in-duration of the valves, with narrowing of theheart’s orilices. All the circumstances of the

cases in these several instances were op-posed to his entertaining any suspicion of theexistence of such an affection in most of the

rheumatic patients. Several of them wereattacked with articular rheumatism, thenfor the first time, having previously enjoyedperfectly good health. This discovery de-termined him on examining the heart andits functions in all the rheumatic patientswith whom he should meet, and the result

was, that he soon ascertained that an acuteaffection of the heart, in cases of acute

articular rheumatism, with violent fever,did not form a merely accidental, or a rarecomplication, but was one of the most ordi-nary accompaniments of that affection.The opinion of medical men up to his own

time respecting the relation between cardiacand rhe umatic inflammation is then reviewed,and the little notice taken by any writer ofthe frequent co-existence of those two affec-tions is pointed out; after which the authorproceeds to determine the law of coincidenceof endo-carditis and peri-carditis, or in-

flammation of the internal and external

sero-fibrous tissue of the heart, with acutearticular rheumatism. This occupies the

first chapter, which he divides into two

articles, in the first he lays down the

generalities of the subject, and states in whatprecise relation endocarditis and pericarditiscoincide with acute articular rheumatism ;in the second he details some particularfacts in support of his views.

Article 1st. Some propositions are here

cited from his work " On Diseases of the

Heart," in the first of which he shows that

pericarditis exists in about one half of thenumber of persons attacked with violentacute articular rheumatism ; that pericar-ditis, is, in some measure, but one of theelements of the disease called "acutearticular rheumatism," which, consideredin a more extended and accurate point ofview than it has been hitherto, constitutesinflammation of all the sero-fibrous tissuesin general; whence, the pericardium beingof a sero-fibrous nature, it is not to be

wondered at that pericarditis so frequentlyco-exists with articular rheumatism. For-

tunately for the soundness of his reasoningour author has appealed to filets, and nottrusted to the assumption which might begrounded on a definition, to prove this co-incidence of these two affections.The number of cases contained in the two

chapters of M. Bouillaud’s work "OnDiseases of the Heart" which treat of

pericarditis and endo-carditis amounts to 92,

635

37 of pericarditis, and 55 of endo-carditis ;of these 92 there were 31 in which the

pericarditis and endo-carditis coincidedwith articular rheumatism, 17 for peri-carditis, and 14 for endo-carditis; so thatin about one-third of the persons labouringunder pericarditis, or endo-carditis, the

presence of articular rheumatism was ascer-tained. With respect to the remaining twothirds, he states that they were not ex-amined with sufficient attention, nor was

the history of their cases known with suffi-cient accuracy to warrant any one in sayingthat articular rheumatism did not exist in

any of them.

Among the circumstances which mighthave put the physician on the road to

discover the fact now under consideration,our author reckons the violent fever, withpalpitotious, the full, strong, and vibratingpulse, sometimes irregular and intermittent,which supervened rather frequently on thearticular fluxion. I

i11 The existence of pericarditis, (says our

author,) in a person labouring under acutearticular rheumatism, may be considered ascertain, when the following symptoms areobserved:-Dulness in the præcordial re-gion, much more extensive than in thenormal state (double or triple in everydirection); distant pulsations of the heartinsensible to the touch, or nearly so; soundsof the heart obscure, accompanied withdifferent anormal sounds, some dependingon the friction of the opposite folds of thepericardium against one another, others de-pending sometimes on the complication ofpericarditis with valvular endocarditis. Apain, more or less acute in the prsecordia.1region, palpitations, irregularities, inequali-ties, and intermissions of the pulse, areoccasionally combined with the precedingsymptoms."The coincidence of endo-carditis with

acute articular rheumatism, our author con-siders to be certain, when the followingsigns present themselves :-" Bruit de soufflet, de râpe, or de scie, in

the præcordial region, which yields a dullsound over a much greater extent than inthe normal state, and also occasionallypresents a considerable prominence, but ina less degree than in pericarditis with ef-fusion ; the pulsations of the heart raise thepraecordial region violently, and they areoften irregular, inequal, and intermittent,accompanied occasionally by a vibratoryfremissement. Pulse hard, strong, vibrating,unequal, intermittent, like the pulsationsof the heart.

" Thus we see that pericarditis and endo-

pericarditis have signs in common, and thatthe physical differential signs are not alwaysvery well marked; so that there are caseswherein it is hard to distinguish whether apericarditis or an endo-carditis exists, orwhether one of those two diseases, oncedetected, exists alone, or in combinationwith the other. These are the cases wherepericarditis may exist with perceptibleeffusion, and merely with the production offalse membranes. The distinction, how-ever, is more curious than useful, the treat-ment being essentially the same. Again, inwell marked cases, nothing is easier than todetect the presence of rheumatic pericarditis,or endocarditis. But of these inflammations,as of all others, there are slight degrees, andhere the diagnosis is more difficult and lesscertain. It is not, however, by cases of thislatter description that our author intends toestablish the coincidence of endo-carditisand pericarditis with acute articularrheumatism. Even the latter disease itselfmight, he says, be frequently overlooked,when slight, if the articulations, instead ofconstituting external parts, became meta-morphosed into internal organs; but still,though overlooked, its existence would notbe the less real. Such is precisely the casewith rheumatism of the serofibrous tissue ofthe heart. Should the individuals die inwhom the signs just mentioned are found toexist, the post-mortem examination detectsthe anatomical characters of pericarditis orendo-carditis."For the purpose of distinguishing between

modification of action, and lesion of structure,with respect to the heart, recourse must behad to percussion and auscultation. With-out this, (says our author,) the distinctionis absolutely impossible, and it is from con-fining themselves to the data afforded by thedynamic or functional signs, such as palpi-tations, irregularity, intermissions in theaction of the heart and pulse, &c., thatmedical men constantly take mere nervousaffections for organic lesions of the heart.To avoid such errors it is only necessary toobserve, that the MM’t-OMS or functional lesionsof the heart, WHEN THEY ARE PURE AND UN-1IIIXED, never produce the above mentionedphysical signs. Thus, then, every time thatwe observe pains, palpitations in the prae-cordial regions, irregularities or intermis-sions in the pulsations of the heart, with orwithout threatening syncope, &c., thosedynamic phenomena not being accompaniedby a normal dullness in the prascordial re-gion, with permanent bruit de souftiet, or derape, &c. &c., we may be certain that thereis neither endo-carditis nor pericarditis.

" If the dynamic, or functional phenomena,now under consideration, be connected withan external rheumatic affection, the lesionon which they depend is to endo-carelitisand pericarditis, just what simple rheumaticneuralgia of the limbs is to rheumatic ar.

636

thritis. This lesion is a sort of rheumaticneuralgia of the heart, whether isolated, oi

combined with neuralgia of the phrenic, 0]the intercostal, or other nerves. But thE

neuralgia of the heart is indicated by a

lesion of motion, and not by real pain,because the nerves of the heart are nerves oimotion and not of sensation ; and in this

point of view the term neuralgia is no moreapplicable here than in the cases where thelesion implied by this term affects externalnerves, which are destined solely for motion.such as that of the facial nerve, forinstance/The author here anticipates an objection

which might be raised against his views :namely, that it is well known that nothing ismore serious than inflammation of the heart,while acute articular rheumatism scarcelyever terminates fatally ; and that it is there-fore impossible that this inflammation of theheart should be so common as he would

indicate. The defect in this attempt to rea-son, M. Bouillaud points out very satis.-

factorily. He says, (which cannot be

denied,) that inflammation of the heart hashitherto appeared to be so fatal, only becauseit was scarcely ever detected, except inindividuals who died from that affection.From the commencement of August, 1835,

to the beginning of the October following,M. Bouillaud collected twenty new cases ofarticular rheumatism, whether recent, or oflong standing. These he divides into three

categories, the first containing cases of acutearticular rheumatism, accompanied with

fever, more or less violent. The third

category includes cases of slight articularrheumatism, unattended with fever. The cat-egory between these two (the second) con-tains the cases in which what is called an

" organic lesion " of the heart, is found inpersons who were formerly affected withacute articular rheumatism, prolonged, andfrequently recurring. This category is

closely connected with the other two. Itcomes in support of the first, and, reciprocally,this comes in support of the other. In fact,we know but one half of a disease when we

study it only in the acute stage. To knowit thoroughly it should be studied in thechronic stage. Org-anic lesion of the laeart,in persons formerly attacked with articularrheumatism, is neither more nor less, ac-

cording to M. Bouillaud, than endo-carditisand pericarditis in a chronic from, that is to isay, with accidental productions, and altera-tion, thickening, and induration of tissueswhich were formerly inflamed, &c.

With respect to the four last cases ofthese twenty, in which the rheumatism wasunattended with fever, he remarks that theyexisted without any affection of the sero-

fibrous membranes of the heart, and that

they are confirmatory of what he had al-

ready deduced from similar cases, namely,that the law of coincidence of endo-carditisand pericarditis with acute articular rheu-matism, is, with some exceptions, applicableonly to those cases in which this disease isaccompanied with fever, and generalised.With respect to the first category, consist-

ing of nine cases, he found that acute rheu-matism of several articulations was ac-

companied by rheumatism of the sero-fibroustissue of the heart. From the considerationof the new cases cited by our author, hefeels himself warranted in laying down thefollowing law regarding this coincidence ofarticular and cardiac inflammation, namely,- That in the great majority of the cases ofacute articular rheumatism, generalised, andaccompanied with fever, there also exists arheumatism of the sero-fibrous tissue of theheart. Of the truth of this law our authorfeels so firmly convinced, as to consider thiscoincidence the rrcle, and non-coincidencethe exception.

After detailing the twenty cases abovealluded to, in confirmation of his views, heproceeds, in his second chapter, to consider"the symptoms, progress, intensity, dura-tion, and termination, of acute articular

rheumatism."" The local symptoms of acute articular

rheumatism are pain, heat, slight redness,and tumefaction, with or without fluctuationof the articulations affected. The subcuta-neous veins around the articulations are

more enlarged than in the normal state. Thetouch increases the pain, as also does theleast motion; and hence that remarkableattitude of immobility which is observablein patients who labour under violent generalrheumatism. Fluctuation, a sign of articu-lar effusion, can only be detected in the largerarticulations, and principally in the knees ; -,there may then be observed two prominenceson each side of the patella, which is raised,and is no longer in contact with the articu-lating surfaces of the femur and tibia. Vio-lent fever, which is greater in proportion tothe number of the joints affected, accom-panies the above-mentioned local symptoms.The pulse is strong, full, hard, vibratingfrom 100 to 120 ; there is considerable heat,and a profuse sweat, which is a little viscid,and of an acid smell, and inundates the eii-tire body of the patients. When the sweat

637

has lasted for some days, the skin, particu-larly in the parts where this humour is mostprofuse, is covered with myriads of sudamina, :often accompanied with a miliary eruptionand red spots, somewhat analogous to thoseof measles. Loss of appetite ; thirst, whichis, in general, very severe; sleeplessness,more or less obstinate, according to the seve-rity of the pains, are also symptoms whichmay be noticed en passant. The coagulumof the blood taken from patients in rheuma-tism is firm, glutinous, and covered with abulfy coat, which is rapidly organized intoa real false membrane, which is thick, dense,and resisting, and analogous to chamoisleather. It floats in the midst of a clear,yellowish, or greenish serum. The edgesof the coagulum are reverted, (renver-ss,) which gives it the form of a mush-room. Sydenham, and also Stoll, have par-ticularly noticed the rheumatic buffy coat.The urine becomes turbid in a little timeafter being passed, and becomes very thick,and it reddens turnsol paper." Generally speaking, the fever of acute

articular rheumatism is more intense thanthat of other acute diseases, and this willbe the more readily understood, now thatwe know the almost constant coincidence of

very severe articular inflammation with thatof the circulating organ." Articular rheumatism, considered in

itself, and abstractedly from its differentcomplications, is susceptible of divers de-grees of variety with respect to its extent,as well as its intensity. Thus, with respectto its extent, it sometimes occupies but asmall number of the joints, as those of thefoot or hand, whilst sometimes it attacksalmost all the joints. With respect to itsintensity, it is sometimes so slight that it !,disappears in twenty-four hours ; sometimesit is so violent as to last for entire months,unless active means be resorted to. When acute rheumatism readily leaves

one or more of the joints, it is in general onlyto attack others. Usually, cœteris paribus,the fixedness and the resistance of acute arti-cular rheumatism, are in the inverse ratioof the number of articulations involved." The mobility of acute articular rheuma-

tism is a phenomenon which has not yetbeen investigated with sufficient rigour. Itmust not be supposed that acute articularrheumatism can disappear easily and rapidly.Let there be, for instance, considerable swel-ling of the knee, with copious effusion intothe joint, &c., and you will see whether it isin a metastasis or an abrupt and sudden re-percussion (delitescence) that the rheumatismwill terminate. Two very different thingshave been here confounded. It is very truethat, even in the case in question, the painof the joint may promptly disappear, withor without the occurrence of a new pain inanother articulation ; but the same thingcannot always be said of the articular effu-

sion, which, however, then constitutes theessential element of the disease. The painis but a sort of neuralgia, which is sympto-matic of the affection of the joint, just whatthe stitch in the side’ is with respect topleuritis ; and in both cases that symptom,common as it is, is still rather an accidentthan an essential character of the disease,since pleuritis may exist without pain, aswell as articular rheumatism, which is, asI may say, nothing but pleuritis of the syno-vial membranes. To say that articular rheu-matism with effusion may always disappearin this way, in the twinkling of an eye,would be to suppose that pericarditis, witheffusion, may also always disappear in thesame manner,-an hypothesis which is totallycontradicted by sound observation."To sum up (says our author), an articular

rheumatism which does not pass that degreewhich may be designated by the term sim-ple fluxion,’ similar to that which accom-panies certain cases of facial neuralgia, maypresent great mobility ; but such is not thecase with more intense articular rheuma-tism, which tends to suppuration, or whichhas already terminated in a purulent or sero-purulent effusion. This, if left to itself,does not terminate till after a certain time;but the pain with which it is at first ac-

companied may disappear a long time beforethe absorption of the articular rheumatism,just as the stitch in the side may disappearbefore the absorption of the pleuritic effu-sion. Thus, then, in the inflammation ofmembranous and parenchymatous structures,the nervous element should not be consi-dered as the fundamental fact, but rather asthe accessory and accidental fact of the dis-ease ; for it may exist without them, and,reciprocally, they may exist without it. Yetwe every day see practitioners take one ofthese things for the other."With respect to the duration of acute ar-

ticular rheumatism, from forty to fifty dayshas been given as the average by severalmedical men, but, as our author observes,the duration of this disease depends verymuch on the treatment employed. Accord-

ing to his plan of treatment, which we shalldescribe presently, the duration of rheu-matism has been diminished by more thanone half, and scarcely ever lasts longer thanfrom a week to a fortnight.M. Bouillaud next notices a very remark-

able fact, the real cause of which remainedhitherto unknown, namely, the continuance.of the fever in some patients whose jointswere entirely freed from the rheumatic affec-tion. The real cause of this fact our author

feels satisfied is rheumatic inflammation ofthe heart, the vessels, the pleura, &c. With

respect to the termination of acute articular

638

rheumatism, it is seldom fatal. However;the endocarditis, the pericarditis, the pleu-ritis, with which it may co-exist, sometimesoccasion death. Another termination of

rheumatism consists in its passing into thechronic state.

In Chapter 3rd M. Bouillaud considersthe anatomical character°s and seat of acutearticular rheumatism. The reason, he states,why the pathological anatomy of acute arti-cular rheumatism is not so advanced as

other parts of its history, is in consequenceof its rarely terminating fatally. Does acutearticular rheumatism occasion an effusionof pus, or of purulent synovia, into the arti-cular cavities, as pericarditis and pleuritisoccasion a collection of pus, or of a sero-

purulent liquid, in the pleura and pericar-dium ? The pus, our author says, has beendenied in latter times, and denied for thisreason,-because rheumatism was not ad-mitted to be an inflammation.

The number of cases of this affection- re-

ported by others, or seen by himself, inwhich post-mortem examination was re-

sorted to, though necessarily small, from thereason already assigned, satisfies M. Bouil-laud that the termination in suppuration orpurulent effusions is not foreign to acutearticular rheumatism. These cases also

prove to his satisfaction that the true and

principal seat of this disease is not in theligaments, as has been maintained by some,but that the real seat of the affection is the

serous membranes of the articulations, orthe synovial membranes. The ligamentoustissues are attacked only accessorily, as

well as several other adjoining parts, suchas the vessels, the external cellular tissueof the joints, &c.

In Chapter 4th he considers the causes ofacute articular rheumatism, which he thinksmay be reduced to one, namely, the influenceof cold combined with moisture. The effectsof this will be so much the greater if it acton an individual whose body is very muchheated, and who is in a state of profuse per-spiration. Muscularfatigue also constitutesa condition which is eminently favourableto the development of this disease. The

influence of cold, after violent exercise, inthe production of the disease, was remarkedby Sydenham. Evident as is the influence

of this cause, our author expresses his asto-nishment that it was ever overlooked, as ithas been lately in the lectures of Professor

Chomel,* who, whilst he admits the influ-ence of cold on the production of muscular,will scarcely allow it to have any in causingarticular, rheumatism. Notwithstanding theauthority of preceding observers, as wellas the facts collected by himself in refer-ence to the great influence of cold on the

development of articular rheumatism, heset about to ascertain, by new observations,what value should be attached to the con-

trary opinion. The result of his observa-tion was, that about fifty patients affectedwith acute articular rheumatism who cameunder his care in the course of the last year,formally stated that their disease had beenoccasioned by alternations of heat and cold.If this be true, we should not be astonishedat rheumatism attacking, chietly, persous

who, by their employments or professions,are exposed to frequent alternations of heatand cold, nor at acute articular rheumatismprevailing principally during those seasonsin which the vicissitudes of heat and coldare very common. Our author here advertsto the fanciful creation of an acrid principle,a rheumatic virus, or humour, so much in-sisted on by some physicians, and expresseshis regret that so excellent an observer asStoll should attach any importance, as heevidently has done, to so chimerical and

gratuitous an hypothesis. He next ex-

presses his amazement at the lengtheneddisputes to which the nature of acute arti-cular rheumatism, and the place it shouldhold in a nosological class, have given birth.Judicious observers have at all times re-

cognised an inflammatory character in acutearticular rheumatism; yet, as it presentssome characters which are not found in other

inflammations, some have thought that it

should be placed among " catarrha," others,among " fluxions." However, as, in the con-tinual progress of science, " catarrhs" and"fluxions," such as those under which acutearticular rheumatism was placed, are nowlost in the immense class of inflammations,it follows that the latter disease itself must

undergo a similar fate.M. Bouillaud here expresses a feeling of

shame at being obliged, at this time of day,to demonstrate the inflammatory nature ofacute articular rheumatism, seeing that somany facts have established the coincidenceof pericarditis and endo-carditis with this

Lancette Frangaise. " Resume de Ia Clin."Jeudi, ler Octobre, 1835.

639

disease. We cannot avoid observing, in

this place, that no one, so far as we know,at least on this side of the channel, everthinks of denying the inflammatory nature of acute articular rheumatism when at itsmaximum of intensity; and we do think,from what we have seen of M. Chomel’s

Lectures on the subject, to whom, princi-pally, our author’s animadversions are di-rected, that that gentleman does not denythe inflammatory character of the disease inquestion. Our French friends sometimesremind us of Pat at the Irish fair, who, afterhaving gone through the entire field, chal-lenging " any man " to fight him, and beingunable to prevail on any simpleton to do so,either from love of Pat or for fun, put on along jock, and trailed it through the field,threatening to knock down every living soulwho would " dare to tread on it." No one

surely could deny the inflammatory natureof a disease which, in its most severe form,is characterised, with respect to its local

symptoms, by pain, redness, heat, and swel-ling, and, in reference to its constitutionalstate, by a most violent and intense fever ;a disease, moreover, which, when it hasterminated fatally, has been found to be

accompanied with suppuration in the arti-

culations ; a disease which is developedunder the same atmospheric conditions asother manifest inflammations, such as an-gina, bronchitis, pleuritis, pneumonia, peri-carditis, &c. ; a disease which, like the

latter, yields to the judicious employment ofbloodletting, and resists all other methods ;a disease, in a word, in which the blooddrawn exhibits, in the most decided manner,the inflammatory buffy coat. M. Bouillaudhere anticipates an objection which may beurged against the inflammatory nature ofthis affection, namely, its character of mo-bility ; and very justly remarks, that if thiscircumstance be irreconcileable wit4 inflam-mation, we must erase from the list of in-flammatory diseases certain erysipelatousaffections certain attacks of angina andcatarrh, which, when slight, may disappearin the space of even twenty-four hours.As for the displacement and abrupt disap-

pearance of articular rheumatism, certainconditions are noticed by M. Bouillaud, theprincipal of which are the following:-1st,the disease being light, and dissemminatedover several articulations from its commence-

ment, circumstances which, to a certain ex-

tent, are correlative, as the disease seems tolose in depth what it gains in extent; 2nd,the influence of the external cause which

produced the first attack, acting on a parthitherto free, and in this case it is not, as isusually said, the rheumatism of a diseasedarticulation which is carried to one whichwas healthy-but the latter being violenlyattacked the other becomes more or less re-

lieved, conformably to the great law of

Hippocrates,-" duobus laboribus simul

obortis non in eodem loco, vehementior ob-scurat alterum ;" 3rd, the general rheuma-tic diathesis, necessarily produced by gene-ral cold succeeding heat, accompanied withperspiration more or less profuse, thoughthis cause may, at the first onset, have occa-sioned an inflammatory fluxion only in somearticulations.

M. Bouillaud here starts another objec-tion which may be offered to him; " Weknow," say his opponents, 11 inflammationof the articulations occasioned by an ex-ternal cause, or traumatic, surgical arthritis,and it does not follow the precise course ofacute articular rheumatism ; the latter thenis not an arthritis." To which he answers :" That it would have been more in point

for them to say that they know non-traumatic,medical arthritis, and that it does not resemblethe affection called acute articular rheuma-tism. He further says, that acute articularrheumatism so closely resembles medicalarthritis, or that produced by a cause whichis non-traumatic, that it is impossible tocite a single case of the latter, if it be notconfounded with acute articular rheumatism.Now, he says, of all the serous membranes,why should the synovial alone be exemptedfrom having their medical inflammation, orthat produced by an internal cause?" Becausepleuritis, pneumonia, pericardi-

tis, which are developed under the influenceof the same causes as those producing acutearticular rheumatism, do not precisely re-semble traumatic pericarditis, pleuritis, andpneumonia, should it be concluded that theformer are not inflammations. The speciesof cause, no doubt, which produces an in-flammation, gives it a particular characterand form, not belonging to the otherinflammations, which are occasioned bydifferent causes, and these particularitiesshould be taken into account; but this doesnot prevent the fundamental nature of theaffection from being essentially the same.Could it be expected, for instance, that auindividual who might be suddenly attacked,after experiencing an alternation of heat andcold, with articular rheumatism in a veryacute form, and scattered over a great num-

640

ber of different points, should experienceprecisely the same set of symptoms as aperson who was affected with inflammationof a single articulation, produced by ablow, a fall, or any local cause whatever ?No reflecting physician would for an instantmaintain such a heresy. Every cause whichproduces simultaneous attacks in several

points of the system, which declares itselfand becomes general, may, at the same timethat it gives rise to real inflammation incertain points, exercise its influence onother parts only to such a degree as to callinto action generltl diathesis, which, withoutbeing well-marked inflammation, is yet astate which really tends to pass into inflam-mation, and, as one might say, inflammationin the nascent, or rudimentary state." Be this as it may, it is evident that the

numerous inflammations of the joints pro-duced by the 2-heuntatic cause, must be lessdeep-seated than traumatic inflammation ofa single one of those joints ; that they mustconsequently adhere less to the parts whichthey attack, be more easily displaced, bereproduced also under the renewed influenceof the cause, as traumatic arthritis woulditself return on the action of a sufficient

power; but with this difference, that in thelatter case there does not exist the generalinflammatory diathesis which favours thedevelopment of a local inflammation in thepoints on which any irritating cause what-ever may act. It may be added, that thesecases of traumatic arthritis do not coincide,like violent attacks of rheumatic arthritis,with acute pericarditis or endo-carditis, andthat the knowledge of this latter eircuni-stance really furnishes us with a key toseveral phenomena which, hitherto, musthave occasioned great embarrassment to

observers. So that, for instance, this rheu-matic or arthritic fever, still present whenthe rheumatism itself is absent, on which isome found their theory of the non-in- Iflammatory essence of this disease, isactually one of the most decisive proofs infavour of the contrary theory. In fact, thecause which keeps up this fever is usuallyan inflammation of the endo-cardium, or thepericardium, an inflammation which is itselfbut a rheumatism of these sera-fibroustissues."

After pursuing this investigation muchfarther, and adducing arguments, which,from obvious reasons, we shall here omit, insupport of the inflammatory nature of arti-cular rheumatism, our author concludes thispart of the subject in the following words:-" Let us avow then, candidly, that in

whatever point of view we consider thedisease called acute articular rheuma-tism,’ it belongs to the great class of

jpMeg-MMcB ; that it even constitutes one ofthe most important species of them, by

reason of the dissemination of the tissueswhich it specially attacks,-tissues whichdo not belong exclusively to the articula-tions, but which are found, on the contrary,in other parts, external and internal: hencethose internal inflammations which coincidewith that of the articulations, and the know-ledge of which has thrown a new and un-expected light on the phenomena of acutearticular rheumatism."

M. Bouillaud next considers the opinionsof the two most distinguished writers of the17th and 18th century on the subject of

rheumatism, namely, Sydenham and Stoll.With respect to the former, he shows at

once that’ he was decidedly of opinion thatrheumatism was essentially inflammatory.The treatment adopted by him proved clearlyhow convinced he was of that. Stoll, also,notwithstanding his theories of " bilious,"" gastric," and 11 saburral" rheumatism,will be found, on close examination, to bean advocate for the inflammatory characterof rheumatism. These theories of Stoll

manifestly refer to the oetiology rather thanto the pathology of the disease in question.We shall now review the author’s ob-

servations with respect to the treatment ofacute articular rheumatism by bloodletting,repeated at short intervals, and the resultsof this formula. To propose a specificmedicine, such as colchicum, or any othermedicine for acute articular rheumatism,would evince but a very unjust idea withrespect to the nature of the disease. As

rational would it be to propose a specificmedicine for pneumonia, another for pleu-ritis, another for pericarditis, &c.

The real specific for acute articular

rheumatism, its quinquina, as he beas leaveto call it, is the antiphlogistic treatment,and the prince of antiphlogistics is blood-

letting, a treatment which has been almostgenerally adopted since the time of Sydell-ham. M. Bouillaud here very fairly re-

marks, that he does not mean to say thatwe cannot cure acute articular rheumatism

except by bloodletting, as that would betantamount to saying that ntitut-e alone doesnot sometimes cure this disease as well asothers. Nor, as he justly observes, is it

sufficient to know that bloodletting is usefulin a disease. It is also necessary to deter-

mine, in a given case, what quantity ofblood should be taken; how often the

operation should be performed; what in-terval there should be between each bleed-

641

ing ; when a repetition of jit is necessary ;whether general be preferable to local

bloodlettings, and rcciprocally; or whetherit may not be better to continue them, andin what proportion. This is what he calls41 dosing," or establishiug a formula of

bloodletting :—It is, says our author, by the modifica-

tions introduced into the methods previouslyadopted, that we have succeeded in obtain-ing results very different from those whichhave hitherto been known, whether in thetreatment of acute diseases in general, or inthat of acute articular rheumatism in

particular. Having been frequently a wit-ness of the interminable duration of acutearticular rheumatism, I determined on

attacking it by regulating the employmentof bloodletting in a different manner fromthat in which it had hitherto been employ-ed. Thoroughly convinced that acute ar-ticular rheumatism was really at the headof the most decided inflammatory diseases,I determined on applying to it the formulaof copious bloodletting at short intervals,precisely in the same manner as it is employ-ed in pneumonia, pleuritis, pericarditis,-in a word, in all those febrile inflammationswhich threaten, more or less, to compromisethe life of the patient. We had recourse tothis method, even before we had well ascer-tained that pericarditis and endo-carditiswere the ordinary companions of acutearticular rheumatism.The success of this method was incredible

to all except those who really saw it. Byits employment the duration of rheumatismbecame, on an average, of about one or twoweeks only, instead of from six to eight.With respect to the mortality, it has hitherto(says M. B.) been none, even in those caseswhere the rheumatism of the joints was ac-companied with that of the heart, and ourobservation proves that those cases are therule, whilst the contrary cases form the

exception. Another advantage deriveablefrom the new formula is, that it prevents thedisease from passing into the chronic state,a serious termination, even when it onlyaffects the joints, but often fatal after ashorter or a longer time, when it is seated inthe heart. And observation proves but tooclearly how common is this latter cir-

cumstance, since probably the half of whatare called " organic lesions of the heart,"are connected with an old rheumatic affec-tion, or are, in other words, of the 11 rheu-matic race."

The formula of bloodletting adopted byour author in general acute articular rheu-matism, attended with considerable fever,is, then, essentially the same as that whichis recommended by him in the article" Pneumonia" in the Dictionnaire de Medicine

et de Chiru1’gie Practiques, and in the article" Pericarditis," in his work on diseases ofthe heart.

11 On the first day of the patient’s admis-sion (supposing him to be of a good con-stitution, and in the vigour of youth) at theevening visit, a bleeding of four palettes isemployed. (In plethoric subjects the firstbleeding is carried to 5 or 6 palettes.)second day. A double bleeding from the

arm, of from 3 to 4 palettes is employed;and, in the interval between those twobleedings, recourse is had to a local bleed-ing, either by leeches, or by the cupping-glasses. * By this local bleeding 3, 4, oreven 5 palettes of blood are taken. The

cupping-glasses are applied around the

joints most affected, and over the praecordialregion, when the heart itself is seriouslyaffected, that is, in the great majority ofcases.

« third day. A bleeding from the armsimilar to that of the preceding day, and asecond application of cupping-glasses (3 or4 palettes), either over the praecordialregion, or around the joints.

" Fourth day. The fever, the pains, theswelling, in a word, all the inflammatorysymptoms, cease after the fourth day; inwhich case no more bleeding is employed,but, in the event of a contrary result, anotherbleeding from the arm, amounting to 3 or4 palettes, is resorted to."Fifth day. Generally speaking, there is

a complete revolution of the disease on thisday. In very severe cases, however, thefever called rheumatic’ may still be suf-ficiently marked, and a bleeding from thearm, amounting to 3 palletes, or else a localbleeding to the same amount, is againemployed." From the sixth, the seventh, or the eighth

day, convalescence is decided, and the

patient may then begin to take nourishment." If serious relapses occur (the new for-

mula does not give absolute security fromsuch occurrences, though probably it ex-poses the patient less to them than the old)a necessity may exist to recur to bleeding.Thus, in a case where four bleedings hadst1’ang ledasevere acute articular rheumatism,a violent relapse supervened, which it re-quired five more bleedings to check.

" If the relapses be slight, we may confineourselves to emollients, diet, broths, opiates,&c., and allow the disease to continue forsome days more. To avoid relapses, themost important precaution to be taken onthe part of the patients, is to avoid, with theutmost care, all exposure to even the leastcold. The means which are to assist blood-letting employed as has now been describ-ed, are, diet, emollient drinks, blisters, com-pression made around the affected joints,I

* This process M. Bouillaud has adopted in

preference, during the last two years..a o

642

and the application of compresses, coveredwith mercurial cerate, over those parts, theposition and attitude of which should bethose which are most favourable for resolu-tion ; emollient cataplasms; baths, and

opium in the ordinary dose, employed eitherinternally or endermically. The mean quan-tity of blood drawn in patients of a strongconstitution, in cases of intense acute arti-cular rheumatism, is from 4 to 5 pounds, asin pneumonia of mean extent and intensity.In certain cases of very severe articular

rheumatism, it may be necessary to take6, 7, or even 8 pounds of blood. In slightcases, on the contrary, the quantity of bloodtaken does not exceed two or three pounds."

It is to be understood, that in the rheu-matism which our author calls " slight,"fever still exists; for in apyretic rheuma-tism one bleeding is often sufficient, andsometimes even that is not necessary. Evenin extreme cases our author states that hehas never been obliged to take twelve

pounds of blood, as other persons state theyhave done, and that, they say, without ar-resting the progress of the disease. Thishe accounts for by stating, that notwith-standing those persons may have taken thelarge quantity of blood above mentioned,yet that they did not take it within the sameshort space of time indicated in his for-mula.

M. Bouillaud concludes his work by thedetails of two cases of very acute arti-

cular rheumatism, which were rapidly curedby bloodletting, employed at very short in-tervals, though in one, at least, of these twothe heart was seriously an’ected.

CASE 1.-This was a case of Acute ArticularRheumatism affecting thefeet, the knees, thehands, the elbows, 8f°c. Fire bloodlettingswere employed in five days, and twentyleeches. Conralescence on the sixth andseventh days after the commencement of thistreatment. No relapse. Quite well on the17th day.11 Berquin (J. B.) 28 years old, of brown

complexion and strong constitution, hadbeen travelling for the last fifteen days,when he was admitted into the hospital onthe 19th of December, 1833. During hisjourney he had been exposed to rain andwind, and had been much fatigued. How-ever, it was not until after five or six daysthat he began to feel pains in the lower extre-mities, which was then so severe as to con-fine him to bed. Nothing had been done inthe way of treatment previous to his ad-mission.

" On the 20th, the pains continued in thejoints of the lower extremities, and parti-

cularly in the knees. The joints of theupper extremities were but slightly affected;there was a little swelling, without any red-ness in the knees ; the least motion increasedthe pain; then the patient continued mo-tionless in the bed, as if in a state of greatprostration; the face was red and flushed;the pulse strong and full, from 96 to 100 perminute ; the skin in a state of perspiration(the sweat was viscid and exhaled a dis-agreeable odour) ; no sleep ; thirst; loss ofappetite; tongue white in the centre, red atthe edges and apex. Prescription:-Twobleedings, to the amount of four palettes;infusion of elderflowers and of white poppy;cataplasms, lavements, and diet.

" 21. Some relief in the pains of the lowerextremities, but an increase in those of theupper; the wrists and hands were swollen,red, and hot, and the slightest motion gavegreat pain. The elbows and shoulders wereless affected. Another bleeding to four

palettes ; twelve leeches to each hand ; theother treatment the same as before.

" 22. There was a general amendment;less of fever, less immobility and prostra-tion ; the wrists were less red and less pain-ful. A fourth bleeding was employed.

" 23. The patient finds himself very well;fever gone ; pulse 80 ; skin of a gentle heat,and moist; no pain. (A bleeding, shouldit be found necessary, in the evening.) At

eight in the evening there was a return ofthe pains in the wrists and shoulders. Inthe morning the pains were diminished.

(The conditional bleeding was not resortedto.)

" 24. The pulse was still strong, full, andhard, from 80 to 84. To put a stop to the

disease, another bleeding, to the amount of3 1/2 palettes, was prescribed. Some chickenbroth was given to the patient. The coa-gulum of the blood drawn at the several

bleedings was covered with a buffy coat, or,rather, a greyish-white membrane, verysmooth on its free surface, and very firm.The proportional quantity of serum increasedfrom the first to the 5th bleeding.

" 25. To-day the patient was perfectlvwell. Pulse from 80 to 84, less hard andless full. Convalescence.

" On the following days no relapse;some return of pain in the joints of theupper extremities, without any redness orswelling. His allowance of food was in-

creased, and simple baths were prescribed.The patient left the hospital on the 5th of

January, perfectly restored."

Here, then, is a case of acute articularrheumatism, occupying nearly all the joints,with intense fever, which was really stran-gled in five days by active treatment, andthe cure was kept up so well that the patientwas able to leave the hospital 17 days afterhis admission.

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CASE 2.-Acute Articular Rheumatism occu-

pying the hands, elbows, scapulo-hutnenalarticulations, the two knees, and the rightfoot. Fiae bleedings in four days. Cata-

plasms over the articulations. Narcotics.Convalescence on the fourth and fifth daystifter the commencement of the treatment." Frances Vilette, a woman of about 27

years of age, a cook, who had never hadany children, came on the 12th of March toLa Charité. Her parents had never com-plained of any rheumatic attacks. Her con-stitution was good. From the age of 18,when she first menstruated, the menses

always came very profusely and regularly.She has been a resident in Paris only forthe last four months, and lived in a damphouse. Her state exposed her frequently tovicissitudes of temperature : she was oftenobliged to descend into the cellar, after

having been heated at the kitchen tire.About five days since she began to complainof slight pain iu the lumbar region, whichcontinued on the two following days. Twodays after, she began to feel considerableconstriction in the knees; but the motion ofthe arms was still free. She felt no heat, noshivering, nor any headach. The pains ofthe lower extremities increased in the courseof the day, and the patient being nowunable to continue her occupation, wasobliged to keep her bed. In the eveninga physician was sent for, who bled her co-piously from the arm, and ordered her aptisan. On the 4th day, the patient, findingher limbs still more affected, entered thehospital.

" March 14. The patient is unable to carrythe right arm to the head ; there is pain inall the joints; countenance flushed; sibilousrale in the anterior and posterior parts ofthe chest. Prescription:-She was bled tofrom three to four palettes, which was re-peated in the evening; infusion of marsh- Imallow flowers, and violet, sweetened withsyrup of gum; mucilaginous mixture, withhalf an ounce of syrup of diacodium.

11 15. She now feels merely a slight numb-ness in the legs, and principally in the rightfoot; but the knees are swollen, red, andpainful. All the joints of the upper extre-mities are affected, the wrists principally so,in the most severe degree ; a little cough,without any expectoration; sibilous raleover the entire chest; résonance every-where good ; pulsations from 104 to 108;28 inspirations per minute ; skin hot, faceflushed; tongue white; thirst; stools andurine natural. The blood first drawn pre-sented a general buffy coat, but was not atall thick, and the last had a partial bufl, butwas thicker. She was I)lc(i to the amountof four palettes from a large orifice. The’ same infusion as before. Cataplasms aroundthe painful joints. Diet.

" 16. The coagulum was cupped; and ex-

tremely dense ; the buffy coat very marked;the arms only were a little numbed, but notso painful as yesterday. The knees, whichwere most affected, are now no longer pain-ful, and the patient can readily bend them ;the tongue less white and less coated ; greatthirst; 88 pulsations ; the patient perspiresvery much. A fourth bleeding to the amountof three palettes." 17. The serum of the blood is predomi-

nant ; the coagulum dense, and covered witha thick, buffy coat, with raised edges. Shewas bled a fifth time, and left the hospitalperfectly recovered on the 26th."We have now presented our readers with

an analysis of this Treatise. The principlesof treatment recommended by the author are,indubitably, excellent; but we cannot givethem all that credit for originality whichour author seems disposed to claim. Perhapsthe intervals between each venesection areshorter than those usually adopted. A workwhose object, like that of the present, is toimprove the treatment of a disease which iss,) common and so distressing, in some of itssequelae, cannot but be acceptable. We knowthat one of the most intractable diseases inthe nosological cadre, and one which so often,if not always, baffles the best-directed enortsof the healing art, namely, organic lesion ofthe heart, is frequently the companion ofacute rheumatism, and, when the latter dis-ease is badly treated, too often the incurableresiduum. We must, however, enter ourdecided protest against the immoderatelyprofuse bleeding which is recommended by51. Bouillaud. We have seen the worst

consequences arise from such treatment. ’&Fa case which lately came to our knowledge,a patient, who was labouring under acuterheumatism, was bled by his medical attend-ant to syncope : the amount of blood taken

was about 30 ounces. The swollen jointssuddenly became quite pale, violent palpi-tation of the heart set in, and in a few daysthe patient died, with all the symptoms ofcardiac disease. Rheumatism is decidedlyinflammatory, but it is an inflammation sui

genfris. It is not to be knocked on the headin a day or two by heroic bleeding, as wesee in the case of pneumonia, pleuritis, &c.We deem it only right to express thus ex-plicitly our disapprobation of a plan oftreatment which is calculated to work suchserious mischief.