26 DR. MOORE on Rheumatic Fever and RheumatiePericarditis.

ART. I I . - -On Rheumatic Fever and Rheumatic Pericarditis. By WILLIA~ MOOR~, A.B.M.B.T.C.D. , Licentiate of the King and Queen s College of Physicians, and of the Royal College of Surgeons~,~ in Ireland.

AcuTE rheumatism is a disease exceedingly distressing to the patient, and fraught with much anxiety to the practitioner, more especially when complicated with an affection of the heart. I have had frequent opportunities of observing the disease, in its sthenic form, amongst a hardy rural population in the north of Ireland, and consider damp and cold east winds the principal exciting causes, but more especially the former : accordingly, November and December are, in the north of Ireland, months most productive of this affection, and, next in order, I should say March and April, owing to the prevalence of these causes.

The first case I shall detail is one of rheumatic fever, un- complicated, occurring in a patient of comparatively advanced years, and although the arthritic symptoms were n~ost acute and prolonged, still the heart remained intact, as it did in two other similarly circumstanced cases which I had an opportunity of seeing during the past winter,--in further corroboration of the law respecting the connexion between the cardiac and arthritic symptoms, laid down by all authorities on the sub- ject, viz., the younger the patient the greater the risk of the heart being engaged, and the comparative immunity from car- diac complications in persons of advanced years.

CAsE I . - -A gentleman, aged 55, of a stout habit of body and plethoric look, had a most severe attack of glossitis, in the month of November, 1852, for which he was freely leeched and otherwise actively treated. After his recovery from this attack he was exposed to cold and wet, and was seized with

~ ains in almost all his joints. When I first saw him I found is appearance anxious; pulse full and quick; tongue furred;

urine loaded with lateritious sediment; profuse sour-smelling perspirations; knee and ankle joints swollen and red, as also were the wrist and elbow joints: in short, he was labouring under all the symptoms of rheumatic fever. From his compa- ratively advanced period of life, and the active treatment he had so recently undergone, I had not recourse to venesection : the treatment consisted in alterative doses of calomel and James' powder, followed by saline aperients, to which, towards the latter stage, was added a fluid scruple of the tincture of colchicum seeds, together with the employment of tepid baths, with excellent effect. After eight weeks' confinement, the pa- tient was enabled to resume his ordinary avocations: the only

Da. MOORE onRfieumatic Fever and RheumaticPericarditls. 27

inconvenience resulting from the attack was comparative stiff- ness and loss of motion in the shoulder and wrist joints, which were much ameliorated by the use of camphor liniment and shampooing. The heart remained intact. I consider this a case of'pure synovial rheumatism: the most prominent feature observable being a direct ratio between the amount of swel- ling and the subsidence of pain in the affected part.

The next case I shall detail is one in which I believe all thefissues of the heart to have been engaged ; it exemplifies the repetition of five attacks of rheumatic fever in the one subject, four of which were complicated with affections of the heart. Hasse, in his Anatomical Descriptions of the Diseases of the Organs of Circulation and Respiration, at page 120", states " that it has been a matter of doubt whether instances really have occurred of general carditis, that is to say, where all three fbrms have coexisted, viz., pericarditis, endocarditis, and myo- carditis." He goes on to state, " but, however rare an in- stance of intense general carditis, the coincidence of the three forms in a minor degree is sufficiently common." I think I am safe in placing the following case under the last category.

In the month of November, 1852, I first visited John Leslie, aged 17, a pale, anemic young man, and found him suffering from rheumatic pains of the elbow, wrist, knee, and ankle joints, with great constitutional disturbance. Under al- terative and diaphoretic treatment, at the end of one month he was convalescent. ~ About the beginning of the month of May following I was again sent for to see him, and found him a se- cond time in confirmed rheumatic fever: the pericardium deeply engaged, as was evidenced by his distressed look, pal- pitation, dyspnea, &c. ; these symptoms had existed for se- veral days previous to my seeing him: I could detect no fr~- missement, the absence of which I attributed to effused fluid; but a loud bruit with both sounds of the heart was audible. I prescribed calomel and Dover's powder in frequently re- peated doses, and applied small blisters over the precordial region. The patient enjoyed comparative good health during the summer and till November tallowing, when I was hur- riedly sent for at 11 o'clock P. ~., early in November, to see him, and found him suffering from distressing palpitation, la- borious respiration, orthopn(~a, violent pain in the precordlal region, with occasional delirium, and all his system pervaded with rheumatism ; fr~missement distinct. Having no means of

a Sydenham Society's edition.

28 DR. Mooa~ on RheumaticFever and Rheumatic Pericarditis.

abstracting blood locally at hand, I bled him from the arm to the amount of" eighteen ounces, With almost immediate relief; got . . . . him under the influence of mercury ; and kept. up. counter- lrratataon by repeated, small bhsters. . He again regained. . con- valescence, but continued dehcate during the winter tall the month of April, 1854, when, for the fourth time, he was seized with pains in all his joints, and the heart was again im- plicated. This comparatively subaeute attack was got under by alterative treatment, combined with wine and nutriment, and the usual counter-irritation, but he did not regain his tone during the entire summer, and about the latter end of August he was seized with a troublesome bronchitis. During the past winter he had another visitation of the rheumatic fever, but in a comparatively chronic form, exceeding the previous attacks in duration, but not in intensity of the symptoms. In the month of May last I examined his chest, the configuration of which I found much altered, viz., a depression under both clavicles, particularly the left, which was made the more re- markable by the bulging out of the cartilages of the third and fourth ribs, owing to the amount of effusion which must have taken place during the repeated cardiac attacks; tumultuous action of the heart, most apparent at the apex. On percussion both lungs were morbidly clear at the top, with marked dul- ness all over the preeordial region, more extensive inferiorly. By the stethoscope I could detect no positive signs of a cavity, but bronchial respiration prevailed over the top of both lungs ; both sounds of the heart were completely replaced by one " whoo," which was strictly confined to the precordial region, but was loudest at the apex of the heart; the action of the heart was so tumultuous as to shove the stethoscope from the ribs with each throb. The patient is attenuated, and racked with a dry cough; pulse weak and compressible; extremities occasionally swollen.

In this case one would naturally conclude that all the tex- tures of the heart must have been engaged: first, we had all the positive symptoms of pericarditis with effusion, with the exception, of the auscultatory., sign of fr~missement. . An o.p- portumty of examinm~ the heart stethoscopacally not being afforded in the first attack; the second time the heart was en- gaged we had all the symptoms of pericarditis, with fr6misse- ment, not so distinct, perhaps, as might have been heard in the first instance, owing to the effused fluid, but still suffi- ciently so to make it unequivocal. Again, in the fourth attack of rheumatic fever, and third of the heart being engaged, we had a bruit with both sounds of' the heart, with tumultuous

Da. Mooa~ on Rheumatic Fever a~d Rheumatic Pericarditls. 29

action indicative of endocarditls, with the muscular substance participating. Since his last attack, which has been subacutc, we have both sounds of the heart replaced by one single bruit, with violent pulsations denoting valvular disease, and hyper- trophy of the muscular substance. On this subject Dr. Watson, in his Lectures on Pericarditis a, says: " Mere adhesion of the pericardium does so embarrass the movements of the heart as to p~oduce at length, sometimes rapidly, sometimes slowly, hypertrophy or other alterations. I t is held too, and I believe justly, though I am not so sure of this as of some of the other points I have been dwelling upon, that the inflammation which begins in the membrane sometimes dips into the muscular substance of the heart, weakens its elasticity.and cohesion, and so lcads ultimately to dilatation of its cavmes."

The next case is one which I would class under the head of endocarditis.

CAsE I I I . - -Pa t r l ek M'Donnell, aged 20, by trade a baker, of an auburn complexion and robust figure, was first seized with rheumatic fever in May, 1854 ; his large joints were prin- cipally affected. In the second attack in November last the heart was implicated, as was evidenced by pain in the precor- dlal region, palpitation, and dyspnc~a, with a bruit accompa- nying both sounds of the heart. Within thelast month I again saw him, suffering from a third rheumatic attack; the endo- cardium again engaged. There was no perceptible dulness on percussion over the region of the heart; slightly increased action, with a loud bruit accompanying both sounds, loudest with the first, and prolonged over the course of the aorta. The young man is now convalescent ; the murmur continues almost with the same intensity, and extends over the same region as when I heard it in the acute stage.

In this case I feel confident there was no pericardial affec- tion ; at least there was not the slightest evidence of effusion or consequent adhesion ; it seemed to me to be an uncomplicated case of endocarditis, obeying all the symptoms of that affec- tion as they have been described by vamous" authors. Dr. Stokes makes the following remarks on the subject of endo- carditis : - - " That its diagnosis depends on the recent produc- tion of a valvular murmur under circumstances indicative of cardiac irritation, or the existence of special morbid states of the system, which predisposes to inflammation of the heart;

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30 Da. Moon~ on Rheumatic Fever and Rheumatic Pericarditis.

and again, where the symptoms of pericarditis are developed, but with the absence of attrition sounds, or evidences of peri- cardial effusion, we may make the diagnosis of endocarditis, especially if there be valvular murmur."

In M'Donnell's case the usual symptoms of the endo- cardium alone bein~ engaged were evidenced by the positive auseultatory sign of the bruit setting up during the course of the cardiac affection, accompanying both sounds of the heart, loudest at the apex, but prolonged over the course of the aorta, and the negative signs of absence of fremissemcnt, and evi- dences of effusion.

As regards the treatment of acute rheumatism and its com- plications, I have nothing new to advance. As in all acute affections, bleeding, general and local, and other antiphlogistie means may be resorted to, commensurate with the stamina of the patient. In dry pericarditis, with excitement of the heart and attended with valvular murmur ; and in pericarditis, with excitement of the heart, and attended with valvular murmur, and the signs of progressive lift uid. effusion, Dr. Stokes. recom-. mends mercury, pushed to sahvatlon, not only wath the view of controlling, the pericarditis, but with the hope of preventing a chronic dasease of the valves. On the subject of counter- irritation, in the form of blisters, I beg leave to make some short comment. I recently read, with great satistZaction, some remarks on blistering, in an able and original article on " Dropsy," by Sir Henry Marsh, in the Number of this Journal for May last. He says: " I f postponed bleeding be injurious, so likewise is premature blistering; before bhsters" are applied the force ,,-~ the heart's action, in an acute case, should be subdued. Now I have witnessed the untimely and injudicious application of blisters in acute dis- eases in general, having, alwa. ys entertained the. . idea that there should be some constitutional treatment exhlbltedpreparatory to their application in order to produce the wishedfor result ; and if it hold in acute diseases in general, dfortiori, how much more in acute rheumatic affections of the heart, where the ac- tion .~ this. organ, is, in the majority of cases, so much increased. . My 1den is, that m an unsubdued attack of any acute disease, where bleeding is inadmissible, and where blistering is the means to be employed, the pyrexia, if I may so call it, conse- sequent on the application of the blister, before the administra- tion of medicine, either alterative or purgative, acts injuriously on the patient, and tends to diminish what we wish most to obtain, a copious flow of white blood. And further, I fear I

DR. J. W. WILLIAMS on U~soundness of Mind, 3yc. 31

have seen cases where it has ignited some latent tendency to strangury, which the preparatory treatment might have ob- viated.

Amongst the lauded specifics for the cure of rheumatism I should be inclined to give colehicum the first place ; I have found it most efficacious especially in synovial rheumatism, or where therewas an admixture of gout. Having seen the hemlock given successfully in other hands, I have repeatedly tried it, but with no very encouraging results. Opium, more especially the preparations of morphia, I should call invaluable in combating the sleeplessness in this disease; and a short time since I saw a case of subacute rheumatic fever treated persistently with alkalies and saline aperients with good effect. In the more chronic stage I should strongly recommend the exhibition of infusion of bark with iodide of potassium, and the use of warm salt water baths, since to these agents the completion of the cure of most of my cases has been mainly attributable.

ART. I I I . - - " Unsoundness of .r in its Medical and Legal Considerations. By JosEe~ W. Wn.LIAMS, L .R.C.S . I . , Licentiate of the King and Queen's College of Physmians, &e.

(Concluded from vol. xix. p. 3730

WE have endeavoured to show the nature of many dit~culties investing the question under our consideration, and for the ap- prebiation of mental diseases we have impressed the necessity of closely scrutinizing, thr~)ugh a careful system of analysis, the psychical and physical relations. It does not, however, follow, because experience haa declared this to be the best, and, we may venture to add, the only reliable plan by which to arrive at truth, that it will, therefore, always prove adequate for our guidance to such an attainment, since cases not unf~equently occur, so strangely anomalous in their character, that medical men of great experience differ widely in their opinions respecting them. Shallow reasoners have thence presumed to argue the inca- pacity of our science rather than to acknowledge its difficulty or obscurity. We are. free to allow the latter, and, in conse- quence, to admit the necessity for our recognition of certain great, principles, . . . . . which may confine, as far as is possible, the solution of scmntlfic problems within the range of scientific certainty, and so, in a great measure, render them independent of individual opinion, the value of which we have already