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Introduction-Frequency and obscurity of the disease-Opinions of
Dr. Watson, Dr. Fuller, and the author-Urate of soda, probable materies morbi— Physiology of urea and uric acid-Liebig's theory in the main correct, but sufficient latitude not allowed for disturbing causes in both health and disease-Becquerel's tables of the comparative quantities of uric acid and urea, as quoted by the late Dr. Golding Bird, reconsidered-Practical conclusions to be drawn therefrom.
In the temperate but ever-changing climate in which we live, there is (with the exception of pulmonary affections) scarcely any malady that so frequently demands the aid of the physician as that of rheumatism; there is scarcely any that is attended with so much suffering to the patient, that so obstinately baffles, at all events for a time, the best directed efforts of medicine to relieve it, and which, when relieved and even apparently cured, so constantly leaves behind it the germs of future, and only too often of fatal organic disease. It is, therefore, for each and
all of these reasons a subject of the utmost practical importance; and, as such, has doubtless on many past, and will again on many future occasions, occupy the serious attention of every practitioner of medicine, from the patres cmscripti of the profession down to its youngest members.
Our anxiety, however, when first called in to a case of acute rheumatism, is not alone dependent on the feeling that we have an obstinate, vigorous, and subtle foe to contend with—which may at any time leave the outworks in which it is temporarily located and entrench itself in the heart, the very
citadel of life—but it is very materially enhanced by the conviction that our treatment of this disease has not hitherto been based on that sound and accurate knowledge of its true and precise nature which is essential in order to enable us to prescribe with confidence and success, and we cannot help admitting to ourselves, with a feeling very much akin to humiliation, that although we have no difficulty in diagnosing the disease —that although we are acquainted with its immediate exciting cause, and recognise it in the aggregation of symptoms then before us as rheumatism, we are still unacquainted with those changes which supervene on the application of the exciting cause, whether in the blood
or in the fibrous tissues themselves, or in bothand which, in fact, constitute the disease itself; and this feeling is in no degree diminished by the recollection that we have on some occasions, in the treatment of this disease, met with such success with one class of remedies as to lead us to believe that the difficulties we had heard described, and even ourselves seen in the treatment of rheumatism, were an exaggeration and a myth, and would in future disappear under the talismanic influence of the last new mode of treatment; and that we have, at another time, under apparently the same circumstances, found that the remedial measures which were previously adopted with so much success, have on subsequent trials proved so ineffectual as to compel us to admit that our knowledge of the true nature of this disease has hitherto been imperfect, and its treatment to a great extent uncertain and empirical.
The question which we first have to decide is, what is rheumatism? Dr. Watson, in his excellent work on the "Principles and Practice of Medicine,"describes rheumatism as inflammation of the fibrous tissues, but yet that it is not inflammation of the common kind ; " at any rate it does not reckon among its events, as common inflammation does, either sur -ion or gangrene. If sup
puration sometimes occurs, and it certainly occurs very rarely, it is because the rheumatismal inflammation has extended to contiguous textures, and then has run the ordinary course of inflammation."
A little further on in the same lecture this eminent and able physician retracts, or at all events' modifies, this opinion in some degree, when he says,
“In truth, acute rheumatism is a blood disease. The circulating blood carries with it a poisonous material, which, by virtue of some mutual or electric affinity, falls upon the fibrous tissues in particular, visiting or quitting them with a variableness that resembles caprice, but is ruled no doubt by definite laws, to us as yet unknown.” Dr. Fuller, who is one of the most recent writers on this subject, believes with Dr. Todd, Dr. Prout, and others, that lactic acid, being retained in the blood instead of being eliminated by the skin, is the special materies morbi of the disease; that this materies morbi is generated within the system and not absorbed from without, and the development is called into play by any long-continued depressing influence upon
the system. When the system is thus deranged, and rheumatic poison is present in it, any disturbing circumstances, even of temporary duration, such as over-fatigue, anxiety,
grief, or anger, by rendering the system more susceptible of its influence, may prove the accidental or exciting cause of the disease, and exposure to cold or atmospheric vicissitudes is almost certain to induce an attack. Dr. Fuller thinks that although the fibrous and fibro-serous textures are those which chiefly suffer, still, from its being a blood disease, all parts of the body must be more or less liable to be affected. *
This view of the pathology of rheumatism is extremely ingenious and highly creditable to Dr. Fuller, but as my views on this subject are entirely at variance with his respecting lactic acid being the materies morbi of rheumatism, and as I dissent from Dr. Watson as to the existence of inflammation of fibrous tissues at all, I am unable to subscribe to the doctrines of either of these gentlemen. It is unnecessary to enter further upon the opinions of others; the controversy would be endless and the result useless. In no class of diseases is the old saying of tot homines tot sententiæ so applicable as in this; most men are content to say, “never mind what it is—can you tell us what will cure it?" A dozen different men would in all probability suggest as many different remedies. The want
* From Braithwaite’s “ Retrospect of Medicine,” vol. xxvii.