The danger in cases of acute rheumatism arises almost entirely from the disease going from the joints to the heart, and setting up pericarditis (q.v.). Hence that mode of treatment will be best which tends most surely to prevent, or, at all events, to lessen the of this complication. If the patient is a young person of robust constitution, and there are well-marked inflammatory symptoms (such as a flushed face and a pulse), he should be at once bled from the arm: A large quantity of blood can usually be taken before any signs of faintness occur, and the bleeding is serviceable in at least. three points of view. In the first place, it almost always mitigates the pain, and diminishes the febrile symptoms; secondly, it enables other remedies, as calomel, opium, colchicum, etc., to act more efficiently; and thirdly, it may occasionally cut short the attack of the disease, which, if not arrested by treatment, may run on for six weeks, two months, or even longer. Unfortunately, however, the cases of rheumatism which are fit to bear free venbsection are comparatively few, especially in large towns; and further, it often happens that the physician is not called in till the proper time for free depletion is past. Pur"iug is probably almost as efficacious as blood-letting, at the beginning of the disease. From five grains to a scruple of calomel given every night, and followed in the morning, for three or four days in succession, by an ordinary black draught, will sometimes dislodge an enormous amount of dark and foul secretions from the liver and bowels, and give marked relief. The main drawback to this mode of treatment is the pain occasioned by changing the position when the bowels act; but this may be to a great extent obviated by the use of the bed-pan. Opium (or morphia) is one of the most valuable remedies in this disease, from its power of allaying pain and procuring sleep. Dr. Corrigan of Dublin trusts to opium alone for the cure. He begins with one grain, and repeats that quantity (or a larger one if necessary) at intervals of two hours, until the pain disappears. He found 12 grains in the 24 hours to be the average amount. required; but half that quantity (or even less) will generally suffice, if the opium he com bined with other remedies, as, for example, if it be given with ipecacuanha (as in Dover's powder), or with small doses of calomel. Colchicum sometimes has a marvelous effect in subduing the disease, but it must be given with extreme care, in consequence of the prostration to which an over-dose gives rise. See POISONS. Dr. Watson believes that this. remedy is of most value when synovial symptoms are present, or when, in other words, the rheumatism approaches in its characters to gout. "Large doses," he observes, "are not requisite. Twenty minims of the wine or of the tincture may be given every six hours until some result is obtained." The abnormal acidity of the various fluids (the sweat, urine, and even the saliva) in acute rheumatism has led to the belief that alkaline remedies would both neutralize the poison, and, from their diuretic properties, tend to eliminate it. The bicarbonate of potash in solution has been largely tried by Dr. Garrod, who administered it in average doses of two scruples every two hours, by night and day, for several days together. Of 51 cases so treated the average period of treatment was between six and seven days, and the average duration of the disease was slightly under a fortnight. The medicine soon rendered the urine alkaline, but did not irritate either the bladder or the intestines. It seemed rapidly to calm the pulse and to allay the febrile heat; and in no case did any heart-complication arise after the patient had been 48 hours under its influence. Other physicians, including the late Dr. Golding Bird, prefer the acetate of potash. The mode of treatment by lemon-juice in doses of 1 or 2 oz. five or six times a day, originally advocated by Dr. G. 0. Rees, at first sight seems in direct antagonism to the alkaline mode of treatment. As, however, the most active principle in the lemon-juice is citrate of potash, which, before it reaches the kid neys, becomes converted into carbonate of potash, there is less essential difference between the acid and the alkaline mode of treatment than at first sight seems to be the case. Some years ago a new and wholly different mode of treating acute rheumatism was warmly advocated by Dr. Davies of the London hospital. It mainly consists in the application of a series of blisters to the parts surrounding and adjacent to the affected joints. One of our highest authorities on this disease, Dr. Fuller of St. George's hos pital, after trying various hot external applications, finds that a mixed alkaline and opiate solution is far more powerful than any, other in allaying acute rheumatic pain. The solution-which lie now usually employs is made by dissolving half an ounce (or rather more) of carbonate of potash or soda in 9 oz. of hot water, and adding 6 fluid drams of Battley's liquor opii sedativus. Thin flannel, soaked in this hot lotion, is applied to the
affected joints, and the whole is wrapped in a covering of thin gutta-percha.
Cases which are intermediate between acute and chronic rheumatism are of very common occurrence. -In those cases of what may be termed subacute rhenthatism there is slight fever, and several joints are usually affected, without intense inflammation in any one joint. These cases soon show signs of amendment under a mild alkaline treat meat, as, for example, a dram of liquor potasstc daily, well diluted and divided into three or four doses, and the moderate use of purgatives.
In all eases of acute and subacute rheumatism, the heart-sounds should be examined daily, or even oftener, with the view of detecting the earliest trace of cardiac affection, and, if possible, of checking its further development. For the treatment to be adopted when there is evidence that the membranes of the heart are affected, the reader is referred to pericarditis (q.v.).
There are two kinds of chronic rheumatism, which are sufficiently distinct to require notice. In one there is considerable local heat and swelling, althoiich unaccompanied with any corresponding constitutional disturbance; while in the other the patient com plains of coldness (rather than heat) and stiffness of the affected joints. The former approximates most closely to the previously described forms of rheumatism, of which it is frequently the sequel, and must be treated in a similar manner; while the latter, which is termed by some the passive form, usually occurs an independent affection. In passive rheumatism the pain is relieved by friction, and the patients are most com fortable when warm in bed—conditions which increase the pain in the former variety. Patients of this kind derive benefit from living in a warm climate, from warm clothing, warm bathing, especially in salt water at a temperature of not less than 100°, the hot-air bath, etc. Friction with some stimulating liniment, and the peculiar manipulation known as shampooing, are here of service; and among the internal remedies, turpentine; cod-liver oil, sulphur, guaiaeum, sarsaparilla, and Dover's powder possess a high reputa tion. Dr. Fuller recommends the muriate of ammonia as a remedy of "singular efficacy"; but of all remedies for this affection there can be little doubt that the most efficacious is the iodide of potassium, given in five-grain doses, combined with a,few grains of carbonate of ammonia three times daily. A patient who is liable to attacks of chronic rheumatism should always wear flannel next the skin during the day, and at night he should sleep between the blankets, abjuring altogether the use of sheets.
RuEumAric DisEAsEs are less common in the lower animals than in men. Horses are not very liable to acute rheumatism, but suffer from a chronic variety, which occurs_ especially In conjunction with influenza. When affecting the limbs it often exhibits its characteristic tendency to shift from one part to another. In cattle and sheep rheu matic disorders arc more common and acute than in horses. The specific inflammation sometimes involves most of the fibrous and fibro-serous textures throughout the body, inducing general stiffness, constipated bowels, and high fever. This is rheumatic fever —the chine-felon or body-garget of the old farriers. Sometimes the disease mainly affects the larger joints, causing intense pain, lameness, and hard swellings; occasionally it is confined to the feet and fetlocks, when it is recognized as bustian-foul; Cattle and sheep on bleak exposed pastures, and cows turned out of the dairy to feed on strong alluvial grazings, are especially subject to rheumatism in its several forms. Among dogs rheumatism is known under the name of kennel lameness, and is very troublesome and intractable in low, damp, cold situations. Blood-letting is rarely admissible except in the most acute cases among cattle. In all animals a laxative should at once be given with some saline matters and colchicum, and when the pain and fever are great, a little tincture of aconite may be added. For cattle, a good combination consists of 1 oz. of niter, 2 drams of powdered colchicum, and 2 fluid drams of the pharmacopoeia tincture of aconite, repeated in water or gruel every three hours: half this dose will suffice for horses. With a simple laxative diet, dogs should have a pill night and morning contain ing five grains of niter and two of colchicum. Comfortable lodgings, a warm bed, horse rugs 'on the body, and bandages on the legs, will greatly expedite a cure. In chronic cases, or after the more acute symptoms are subdued, an ounce of oil of turpentine, and two drams each of niter and powdered colchicum should be given for a cow, half that quantity for a horse, one-fourth for a sheep. Hartshorn and oil, or other stimulating ernbrocations, diligently and frequently rubbed in, will often abate the pain and swelling of the affected joints.