RHEUMATISM 517 or complications which are apt to attend its progress. Among these may be mentioned excessive fever (hyper- pyrexia), which is sometimes developed in a sudden and alarming manner, the temperature rising quickly to 108-110 or more, and thus endangering life. Indeed in most of such instances death speedily follows unless prompt treatment be resorted to. Another danger is the occurrence of serious head symptoms in the form of delirium or excitement, which may exist in conjunction with hyperpyrexia or independently. Chorea or St Vitus's dance is also an occasional accompaniment of acute rheumatism. Besides these, other complications pertaining to the respiratory organs, such as pleurisy, pneumonia, bronchitis, &c., sometimes arise in the course of the disease, as well as certain disorders of the skin. But the most frequent and important of all are those affecting the heart. These cardiac affections are regarded by some as an integral part of the rheumatic disease rather than as results of it, especially as it would seem that occasionally they are the only local manifestation of the attack. Pericarditis (inflammation of the investing membrane of the heart) and endocarditis (inflammation of the lining membrane of the heart) are the two most common forms which these heart complications assume, and it is the latter which is specially important as tending to lay the foundation for valvular heart disease (see HEART). It is the liability to these inflammatory heart affections that causes special anxiety during the earlier stages of an attack of acute rheumatism, when it would appear they are more apt to occur. The risk of cardiac complications seems to be greater the younger the patient, and doubt- less the foundation of organic heart disease is often laid in early childhood, when, as is now well known, rheumatism is by no means uncommon. The name subacute rheumatism is sometimes applied to attacks of the disease of less severe type than that now described, but where yet the symptoms exist in a well- marked degree. Cases of this kind may be of even longer duration and more intractable than the more acute variety, although probably the danger to the heart is less. CHRONIC RHEUMATISM appears occasionally to be deve- loped as the result of the acute form, but is more frequently an independent constitutional affection, and is usually a complaint of later life. The causes associated with its occurrence are habitual exposure to cold and damp; hence its frequency among outdoor workers. It is also apt to arise in persons debilitated by overwork or privation. Certain poisons introduced into the system are often attended with symptoms of chronic rheumatism, e.g., lead, syphilis, &c. This disease is often hereditary. It differs from acute rheumatism in being less frequently attended with fever and constitutional disturbance and less liable to dangerous complications, but on the other hand it is much more apt to produce permanent alterations in the joints and parts affected. The joints tend to become swollen both from effusion of fluid and from chronic inflammatory thickening of the textures, and the result is stiffness and sometimes complete immobility. But in addition the sheaths of muscles and of nerves are apt to be affected by chronic rheumatism, causing much suffering. This form of rheumatism is less migratory in its progress than the acute, and tends to remain fixed in a few joints, often in those which are specially exposed to atmospheric influences or to overwork. The chief symptoms are pain and stiffness in movement, more particularly when the efforts begin to be made, becoming less after the limbs and body have been in exercise. Creaking or crackling noises accompany the movements. The pain is apt to be increased during the night, and is besides markedly influenced by the state of the atmosphere, cold and damp aggravating it. This form of rheumatism, although not directly danger- ous to life, tends to lower the health and render the patient more vulnerable to other morbid influences. Besides this, by long continuance it may lead to great deformity and disablement of the frame, in some instances resulting in a condition of utter helplessness. Treatment. Few diseases have had so many remedies recommended for their alleviation, and vaunted as specifics, as rheumatism ; and, when it is remembered how many are the theories of the nature of the malady, it is obvious that even as regards principles the methods proposed must be numerous and diverse. Nevertheless, there are certain well-recognized systems of treatment which in most instances will be found to be of benefit. The treatment differs in the two forms of the disease. As regards acute rheumatism the general management of the case from the outset requires attention. The patient should be placed in bed between blankets, and should wear a flannel shirt, the front and arms of which should be opened to admit of the examination of the heart and of the joints. Move- ments of all kinds should be as far as possible avoided. The affected joints should be enveloped in cotton wool, kept in position by a light bandage. Sometimes the bathing of these parts with warm water containing opium or other sedative affords relief. The local application of blisters in the neighbourhood of the painful joints, as pro- posed by Dr Herbert Davies, is in some instances followed with benefit, but is obviously applicable only where the rheumatism is limited in its extent. The same may be said of the local application of electricity to the joints. Constitutional remedies are of undoubted value in this disease, and the number of available agents for this purpose is so large that mention can only be briefly made of some of the more approved. For long the alkalis, especially the salts of potassium, were the chief remedies resorted to, and for them it was claimed that they shortened the attack, relieved pain, and prevented heart complications. They are certainly very valuable in many instances. Of late a new series of substances has been tried with great success, namely salicin (first suggested for acute rheumatism by Dr T. J. Maclagan), salicylic acid, and salicylate of soda. These remedies, which are known to have a powerful effect in reducing febrile temperatures, appear to exercise a special influence in acute rheumatism, not merely by lowering the fever, but by relieving pain and cutting short the attack, thereby lessening the risk of complications. From 20 to 30 grains of these drugs every two hours require to be given for about twenty-four hours in order to produce the desired effect, and the quantity is reduced as the acute symptoms subside. Although they do not succeed in all cases, and sometimes give rise to symptoms (delirium, sickness, &c.) which necessitate their suspension, it will be admitted by most physicians that cases which appeared likely to be of a severe character have under this treatment been cut short in a few days, and that even where this result was not attained the pain and other distressing symptoms were materially alleviated. Tonics, such as iron and quinine, have also been employed in acute rheumatism, but their advantage is more apparent in the convalescence, when there are anaemia and debility, rather than in the height of the disease. The pain and sleeplessness may render necessary the administration of opiates, but in many instances both are completely overcome by the remedies previously mentioned. In the dangerous complication of hyperpyrexia the cold bath (in which the water is quickly cooled down from 94 to 68) has frequently been suc- cessful in speedily lowering the temperature and saving life. Persons who have suffered from acute rheumatism should ever afterwards be careful to avoid exposure to
