DR. MACLEOD ON RHEUMATISM.
IN point of composition, Dr. MACLEOD'S work on Rheumatism may be recommended as a model for a treatise on a particular disease : the arrangement is methodical, the style clear without any attempt at ornament or force ; the particular facts, containing specific con- clusions, well selected to illustrate the views, and the general facts—the statistics of the subject—distinctly presented ; every thing is done and nothing overdone.
Nor is the work less meritorious in a medical point of view, what- ever judgment may be passed on the Doctor's opinion. In the treatise on Rheumatism there is no rash speculation, no theory ad- vanced on conjecture or little better than conjecture, and no wonder- working specific held out to catch the vulgar. The principle on which Dr. MACLEOD appears to have proceeded in the study of this disorder, was to make himself acquainted with the views of other authors, and to give them attentive consideration, but to place his chief reliance upon nature ; giving various remedies a fair trial, but continuing in the use of those which ba found by experience to be the most beneficial ; watching and recording the particulars of
every case, and when death ensued, and opportunity permitted, investigating the morbid anatomy of the disease by a post mortem examination. From this actual observation of nature, continued for many years in hospital as well as private practice, Dr. MACLEOD deduces his conclusions; which, if they do not exhibit any striking novelty, present what is known in a more distinct and classified form than it has yet appeared in, besides reducing that which was scattered, floating, or obscure, to a definite and tangible shape. The most original points of Dr. MACLEOD'S book appear to us to be, his opinion that disease of the heart following rheumatism is an ex. tension, not a change of the disorder ; his exposition of inflammation of the membranes of the brain, which sometimes attends capsular rheumatism; and his view of the periosteal variety. In Dr. MACLEOD'S judgment, much of the contrariety of opinion found in medical works, and the various practice adopted in the treatment of rheumatism, may be ascribed to the want of an ac- curate description of the species of disease spoken of. These species he himself arranges under six heads.
1. Rheumatic fever, or acute rheumatism; that is the most common form of the disease, and what is popularly understood by rheumatism.
2. An affection of the heart arising from rheumatic fever ; which many maintain to be a metastasis or change of disorder, but Dr. MACLEOD considers it merely an extension of the existing inflammation.
3. Capsular rheumatism is a disease limited to particular joints ; the capsular ligament being the loose bag which contains the lubricating liquid of the joints. This variety of the disease seldom extends to the heart ; but it sometimes changes into a "slow and treacherous inflow motion about the brain, producing fatal effects without exciting the general system into any of that sympathy which usually attends the progress of mortal diseases." Another form of this metastasis goes silently on to a certain point, when its existence is pointed out by pain in the head ; but it seems that the pain and the mortal injury are deve- loped together.
4. Muscular, or, as it is often called, chronic rheumatism ; which is not to be considered as the mitigated kind of the preceding forms of disease often met with, beta distinct disorder, whose most common seat is some of the large muscles moving some of the large joints : lum- bago is a well-known variety of this form.
5. Neuralgic rheumatism; whose principal seats are the sciatic re- gion, the thigh, and the leg, though occasionally met with in other parts. The sciatica is a well-known type of this disease.
6. Periosteal rheumatism ; a thickening of the periosteum, or mem- brane which surrounds the bones ; generally attributed to a syphilitic or mercurial origin, but Dr. MACLEOD considers that it is often a form of rheumatism.
Of these six varieties, the three first are the most important, from their frequency, their pain, and their danger; as they are the most fully treated by Di. MACLEOD. Into the principles or prac- tice of these forms of rheumatism it is not our intention to follow this author; but we will select some of the more striking facts con- nected with the subject, so as to present a view of the statistics of rheumatism.
The origin of rheumatism is frequently attributed to cold; but Dr. MACLEOD attributes it less to cold than to atmospheric vicissi- tudes; and one authority estimates the proportion of cases "occur- ring in summer to those occurring in winter as five to seven." It is a general opinion that rheumatism arises from some constitutional predisposition; and the facts of Dr. MACLEOD confirm this view. An individual whose parents have suffered from the disease, or who has once been afflicted with it himself, is more liable to attacks than other persons ; and CHOMEL states that at La Charite, not less than one-half of the patients treated by him for rheumatism were the offspring of rheumatic parents. From the records preserved, men are more subject to it than women ; probably from greater ex- posure. It prevails most in youth and early manhood ; probably two-thirds of the patients are between fifteen and thirty ; our au- thor has frequently seen it in children of five or six years of age. It is also met with in infancy ; but "as we advance in life, the lia- bility to the disease in the form of rheumatic fever diminishes, and it is comparatively rare after fifty." Among the class of persona admitted to public hospitals, that is among the poor, rheumatism is a disease exceedingly prevalent. "Indeed," says Dr. MACLEOD, "I am satisfied that all medical men connected with those institu- tions will bear me out in the assertion, that, if we take into account the ulterior effects of acute rheumatism, it is not only one of incident to most prevalent, but one of' the most fatal maladies to our precarious climate." (It must, however, be remembered, that, consumption rarely taking the form of acute disease, the patients generally die at home.) A singular peculiarity attends rheumatic fever, that notwithstanding "the violence of the in- flammation, and its extension to the integuments and to the deeper- seated structures, it is a kind of inflammation little prone to disorganization,"—that is to change the substance of parts—except when it extends to the region of the heart. This exception, how- ever, is a pretty broad one • for BOUILLARD estimates these af- fections of the heart at nearly one-half, and Dr. MACLEOD leans to the same conclusion ; considering, however, that they follow severe attacks, and it would appear come on with great rapidity.
LOOK AND SYMPTOMS OF RHEUMATIC AFFECTION OF THE HEART.
Of the general symptoms which indicate that the heart has become implicated in an attack of acute rheumatism, the most striking is the aspect at the patient. I venture to say there is no observant practitioner who has not bad occasion, on going into the wards of an hospital, to stop at once on coming to a rheumatic patient whom be may have seen the day before apparently doing well, and proceed to examine the heart with the conviction on his mind, before be has asked a single question, or applied his stethoscope, that carditis has supervened in the interval. This is one of the many instances in which the e) e can detect what the pen cannot express. The system has taken the alarm at the new inroad of the malady ; the consequent distress is depicted in the countenance, and told in every attitude and every movement. The expression is anxious ; the breathing rather shallow; occasionally there is cough. The patient is sometimes very restless, but more generally lies on the back or right side; at least it is rare to see him choose the left. Here we have intense fever, but for the most part without the restlessness and tossing that usually attend that state. Indeed, there is occasionally a fixedness in the general aspect—I bad almost said in the deportment of the patient—quite remarkable : he becomes, as it were' passive ; and while the immobility with which he retains one position would lead us to suppose that any other would be intolerable to him. yet I have known such a patient, upon being moved, remain in his new position ap- parently as determinedly as he had previously done in the other. Although, therefore, reclining on the back, or a little to the right, be the most common, and therefore, we roust presume, generally the easiest posture, yet the unwilling- ness to move, even to resume this attitude, probably depends upon the effect produced by motion of any kind on the heart's action, which thus becomes for the time still further embarrassed. In the cases where this unwillingness to any change of posture is most marked, the action of the heart is usually feeble and the sounds indistinct.
Although the treatment of these complaints is a matter for the practitioner, who will form his opinion on something more autho- ritative than a review, yet we may say that Dr. MACLEOD strongly recommends copious blood-letting in the earlier stages of acute rheumatism; by which he finds the disease is frequently cut short ; nor does be consider that venesection has a tendency in any case to increase, but to prevent the extension of the disorder to the heart. The extent and repetition of the bleeding must depend upon circumstances, whilst in delicate patients it may be desirable to avoid it altogether. The next remedy to bleeding is purging; which ought to be continued freely at first, and the due evacuation of the bowels never to be lost sight of. Opium follows purgatives ; but we should incline to think its virtue rather consists in alle- viating the symptoms than in removing the disease. Sudorifics Dr. MaeLKon considers of little value ; and bark, he thinks, aggravates the complaint.
Active cure, however, is for the physician; preventive cure for the patient : and the views of Dr. MACLEOD on this point are easily understood, and not of difficult practice to many persons. They are—wear chamois leather next the akin; use the flesh-brush night and morning, (beginning, we should say, in warm weather); avoid unnecessary exposure to atmospheric vicissitudes ; and keep the feet and general surface warm, without being over-heated.
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