[Reprint from The Medical and Surgical Reporter of July 3, 1886.] 
DEDUCTIONS FROM NINETY-ONE (91) CASES OF RHEUMATISM, 
BEING A CONSIDERATION OF THE REPORT OF THE COMMITTEE ON THE 
COLLECTIVE INVESTIGATION OF DISEASE 
OF the 
MEDICAL SOCIETY OF THE STATE OF PENNSYLVANIA. 
By WILLIAM A. EDWARDS, M. D., 
Member of the Committee, Instructor in Clinical Medicine and Physician to the Medical 
Dispensary in the University of Pennsylvania, Physician to Saint 
Joseph’s Hospital, etc., etc. 
The study of disease by the collective 
method is of value in direct proportion to 
the number and character of tbe replies that 
are received. When we compare the report 
of the above committee to that of the com- 
mittee of the British Medical Association, 
in which, for instance, 1066 cases of pneu- 
monia are tabulated, it will at once become 
apparent how extremely valuable these re- 
ports may be made when vast numbers of 
cases are recorded from which reliable con- 
clusions can be derived; still a careful per- 
usal of these ninety-one cases will amply re- 
pay one for the time and thought expended. 
Sex appears to have presented a direct 
predisposing cause to the disease, as of the 
cases reported 58 were males and 32 females,* 
thus again establishing the well-known state- 
ment of the books that acute rheumatism is 
more frequent in men than in women, an 
undisputed fact for many years, as Hip- 
pocrates in his Aphorisms states that women 
are less liable than men; but as we shall see 
later, the report seems to disprove the state- 
ment that this is due to the fact that men 
are more exposed to the influences produc- 
ing it, and not because of a greater suscep- 
tibility to the disease ; we shall also see that 
the greatest number of cases are recorded 
among “housekeepers,” an occupation in 
which it would be an extremely difficult 
matter to establish any special relation to 
rheumatism. Again, among the males we 
find that the greatest number of cases are 
recorded among “ farmers,” once more a 
business that is not nearly so exposed as 
others recorded in the report, and would not 
; seem to offer such a predisposing environ- 
ment as, for example, an “ ironmonger,” a 
“ puddler,” a “ miner,” or a “ daily laborer.” 
It would most certainly seem that an occu- 
pation that entailed protracted exposure in 
damp apartments (miner), or exposure of 
the body to cold or wet when in a perspiring 
state (puddlers), would be a decided exciting 
cause; yet the report does not bear this out, 
but it does show in a striking manner the 
frequency with which rheumatic attacks fol- 
low ordinary exposure to cold or to chilling 
the superficies of the body in those of the 
rheumatic diathesis. 
The rationale of these attacks would seem 
to be that during the use of the body, i. e., 
the muscles, lactic acid and acid potassium 
phosphate are produced, and when the body 
is chilled, the elimination of these matters is 
stopped, hence an accumulation occurs, and 
with it the resulting rheumatic outbreak. It 
is proper to state, however, that Reyher * 
does not regard the accumulation of the 
* One case sex not stated. 
* Virchow’s Arch., voi. xxi., p. 85, quoted by Bartholow. 2 
acid in the blood as a cause of rheumatism, 
Prout and Richardson, however, are as firm 
advocates of the affirmative side of the ques- 
tion, the latter having demonstrated the fact 
that injections of lactic acid are followed by 
endocarditis, and that its medicinal adminis- 
tration in diabetes has in various instances 
apparently caused a rheumatic inflammation 
of the joints. 
The relation of the use and abuse of alco- 
hol in its various forms to the disease is of 
sufficient importance to claim our attention. 
While the returns in this matter are not 
as full or concise as we all would desire, still 
they are sufficient for the purpose, and show 
that restriction in the use of alcoholic stim- 
ulants is requisite to the welfare of a rheum- 
atic. Sir Thomas Watson so aptly remarks 
that the instances are not few of men of 
good sense and masters of themselves, who, 
being warned by one visitation of the gout, 
have thenceforward resolutely abstained from 
rich living and from wine and strong drink 
of all kinds, and who have been rewarded for 
their prudence and self-denial by complete 
immunity from any return of the disease, or 
upon whom at any rate its future assaults 
have been few and feeble. “ I am sure it is 
worth any young man’s while who has had 
the gout to become a teetotaller.” 
To return to the report, we find that four 
(4) of the males are recorded as “intemper- 
ate,” and that none of the females are so re- 
corded. Thirtv-four cases are stated to be 
“ total abstainers,” and fifty-one cases “ tem- 
perate.” The nature of the attack in these 
cases would show to a certain extent the 
effect or non-effect of alcohol upon the disease. 
Of the total abstainers, we find that eleven 
were subjected to a moderate attack and thir- 
teen to a severe. Of the fifty-one temperate 
cases, twenty had a moderate attack and 
thirty-one a severe. Of the alcoholics (four) 
one had a moderate attack and three a severe. 
In one temperate case and in one total ab- 
stainer the nature of the attack is not stated. 
To consider this matter more closely, we 
notice an apparent contradiction in the fact 
that of the non-alcoholics nearly twice as 
many are noted to have had a severe attack 
as compared to those recorded as “moder- 
ate;” this is due to the small number of re- 
turns, as when we compare the nature or 
the attack in the intemperate, we find the 
ratio of severe to moderate as one is to three. 
It seems, then, to be established, by this 
report, that over-indulgence in alcoholic 
liquors will, if associated with certain other 
conditions already referred to, undoubtedly 
give rise to or be a decided setiological fac- 
tor in the production of an acute attack of 
rheumatism. 
It does not seem to be of much importance 
which of the liquors are used, but the 
amount of alcohol contained therein is of 
great significance. The mischievous effect 
of liquors appears to be in direct proportion 
to the amount of alcohol which they repre- 
sent; it is a somewhat general statement 
that the stronger wines, as port, sherry, and 
madeira, are much more injurious in this re- 
spect than the lighter wines, as hock, sau- 
terne, or moselle. By many, malt liquors 
are considered the most injurious, but the 
question as to which is the most or least de- 
sirable is still sub judice. 
An inquiry regarding the food elicits the fact 
that of the ninety-one cases, but one had “ in- 
sufficient” recorded. This patient, a woman, 
jet. 46, housekeeper, had been exposed to 
wet and cold a few days before the attack, 
which was moderate in character, lasting ten 
days, from which she made a perfect recov- 
ery, with, however, a slight persistence of the 
disease in three joints. 
The effect of climate upon the disease, as 
shown by the report, is that the greatest 
number of cases occur in “ high, dry, ex- 
posed ” localities, with the atmosphere “damp, 
wet, and cold,” and with the wind blowing 
from either the west or northwest; this, re- 
member, is the climatology of Pennsylvania 
alone in relation to the disease, as the cases 
are taken from the various towms, cities, bor- 
oughs, villages, and hamlets throughout the 
State. 
Among the predisposing causes may also 
be added exposure to over-fatigue which oc- 
curred in sixteen males and five females ; in 
four of the former and two of the latter the 
fatigue wTas sudden. Shock preceded the at- 
tack four times—three times in males and 
once in females. 
Age appears to bear no particular relation 
to the disease, as the youngest case was nine 
months, and the oldest sixty years. Again, 
a severe attack is noted in a child aet. 
ten months, and a mild one in a man set. 
sixty years. The investigation of the condi- 
tion of the peri- and endocardium in the 
series of cases becomes indeed an interesting 
part of our study. The known tendency of 
the rheumatic poison to these membranes, let 
it be what you will, adds renewed interest to 
their consideration. 
The condition of the circulatory apparatus 
was noted in twenty-four cases, an extremely 
small relative proportion, if it represents the 
true relation of the occurrence of cardiac 
complications in the ninety-one cases. 3 
In fourteen instances was the pericardium 
attacked; twice was the mitral valve diseased. 
One observer notes “ a distinct murmur dur- 
ing the attack, with apex beat lowered to 
seventh interspace.” Four cases are recorded 
as having “ heart disease, before, during, and 
after attack, with pericarditis, murmur, and 
lowering of apex beat.” Two cases of mur- 
mur following the attack are placed on 
record. One case of pericarditis, which ex- 
isted previous to the attack, was not appar- 
ently affected by the rheumatic complication. 
One somewhat extraordinary case is noted of 
“ pericarditis only during attack, with low- 
ering of apex beat.” 
The cutaneous system was but rarely af- 
fected ; the following skin eruptions are re- 
corded: Erythema 2, eczema 2, and one 
example of these eruptions: papular, blebs, 
herpes, sudamina, furuncles, roseola (after 
attack). Subcutaneous nodules are recorded 
as occurring but in seven (7) cases. 
Without further comment upon special 
symptoms, we will proceed to a consideration 
of the methods of treatment pursued by the 
various observers. That most usually advo- 
cated is the general plan of therapeusis, 
comprised under the somewhat comprehen- 
sive term of “ alkaline.” Salicylic acid and 
the salicylates, followed by, or combined with 
quinine, seems to have been a very efficacious 
combination. Salicylate of ammonia is an 
alkali worthy of special mention, on account 
of the happy combination of the two drugs, 
particularly in asthenic cases. The iodide of 
potassium was exhibited in many cases with 
apparent happy results. One reporter is an 
advocate of frequent catharsis; another, of 
vapor baths. Again, we note the advocacy 
of cold sponge baths; leeches were also ap- 
plied. The efficacy of dietetics was proven 
by the frequent happy recourse to a “ milk 
diet.” Mercurial inunctions and the faradic 
current in two instances appeared to prove 
beneficial. Tincture of the chloride of iron 
during convalescence, in many instances, ap- 
parently hastened a more speedy return to 
the normal blood crasis. An observer re- 
ports that “ the rheumatic list in the materia 
medica ” was exhibited to his patient without 
any apparent amelioration of the symptoms. 
Again, a plan of treatment styled as “anti- 
rheumatic,” is reported. Opium was in many 
cases the keystone of the treatment; indeed, 
few cases are recorded in which the drug was 
not exhibited at some time during the course 
of observation. 
The following drugs are reported as having 
been used with varying success, and upon 
scanning the list we will notice that the drugs 
exhibited are almost as numerous as the 
number of cases recorded: Digitalis, gaul- 
theria, soda biborat., sulphite of soda, iron, 
cod liver oil, vin. colchicum, pulv. ipecac et 
opii, pot. carb., magnesia sulph., jaborandi, 
aconite, veratrium viride, nitrate, citrate, and 
acetate of potash, lemon juice, fluid extract 
cimicifuga, hydriodic acid, potas. et sodse 
tart., hyoscyamus, gelsemium, mass, hy- 
drarg., fi. ext. manaca, guiac. citrate lithia, 
sulph. codeia, coto bark. 
1504 Walnut St., Phila.