over her body, and continuing to reappear, in spite of every sort of treatment, for many months. To these cases I shall add an experiment with variolous and vaccine virus, which appears to bear on the question of secretion, as being the mode by which contagions multiply. A person having been inoculated at the same time, and nearly on the same spot, with both poisons, as the resulting vesicles proceeded in their course, they, being so close to one another, coalesced so as to form a single pock, one side of which furnished the variolous, the other the vaccine virus. It is scarcely to be supposed that if the poison of smallpox multiplies itself in the blood prior to its appearance in the vesicles, it would have been excluded in this instance from the vaccine side of the pock, when this was becoming expanded with a substance so closely akin to itself. This experiment in common with all those in which simultaneous inoculation with the two poisons produced pocks which yielded, each, that poison only to which it owed its origin, appears much more in accordance with the doctrine of a specific affection of the inflamed part being the source of the new matter, than with any other conceivable explanation. Have we not, also, in that incapacity of the skin to be again excited, in one who at a former period had been affected with small-pox or vaccinia, even by inoculation to exhibit that peculiar form of vesicular disease which distinguishes those affections in persons who have not undergone that "inconceivably minute," but yet most important, change which follows when either has been onće experienced, evidence of an implication of the solids in a very remarkable degree in the action of those poisons on the body; evidence the most direct of a singular alteration in the constitution of the living tissues, while we have none whatever of an alteration of any kind having been produced in the constitution of the blood. Inoculation with either virus produces no other effect, when it produces any, on one who continues to enjoy the protection of a previous experience of the disorder, but some redness and swelling at the seat of the puncture, such as might follow the insertion of any other irritating substance into the skin. (To be continued.) VOL. X, NO. XLI.-JULY, 1852. 2 F 434 ON CARDIAC DISEASE, ORIGINATING IN RHEUMATISM OF THE HEART, Every one who practises physic knows how often organic disease of the heart is the consequence of rheumatism or rheumatic fever-but I think the profession is not generally aware, how very often such disease would seem to be of rheumatic origin in patients who have never had rheumatic fever, or suffered from rheumatism in any of their joints. From several cases that have come before me, I am led to believe that disease of the heart is a frequent consequence of an acute rheumatism that expends itself entirely on that organ, without showing itself on the joints primarily, or giving rise to what is called rheumatic fever. Just as there are cases of rheumatic fever in which the joints are alone attacked and the heart may not at all participate-so, I believe, there are other cases in which, so to speak, the whole virus of the disease concentrates itself upon the heart alone and leaves the joints altogether unaffected. It is, I think, very generally supposed that rheumatic fever precedes or accompanies the development of endo-cardial and pericardial inflammation, when that inflammation is rheumatic in its character-whereas, I believe that such inflammation may occur not only as a primary disease in which the joints are affected secondarily, but that very often it occurs as such without the joints being touched at all. In other words, I am disposed to believe that acute inflammation of the textures of the heart is, except when rheumatic, of rare occurrence—and that rheumatic inflammation is more frequent than is supposed,being often only unrecognized as such, because unaccompanied by affection of the joints, or unpreceded by rheumatic fever. I am not aware that any writer has made this point as clear as it appears to me. It has been shown how often disease of the heart is a consequence or concomitant of rheumatic fever-but it has not been shown, as far as I am aware, how often the heart is the sole seat of rheumatism-how often it is invaded by rheuma tic inflammation without the joints participating therein.-This is my reason for bringing the subject before the notice of the medical profession-though I am sorry to say that the cases I have recorded are far too few to generalize from, or to serve for its illustration. My principal object in the present paper is to call the attention of my brethren to the subject, reserving to myself, at some future time, the task of doing it more justice than at present. Meanwhile, perhaps the following cases, preserved out of several that are unrecorded, may put my views in a clearer light. E. J, the son of a butcher-a boy of about three years of age-was brought to me, the beginning of last year, suffering, I might say, from general anasarca. Face- arms-legs-abdomen in short-the whole of the cellular texture was invaded by dropsy evidently depending on organic disease of the heart. Of this there could be no doubt. The very tumultuous action of the heart-the dulness on percussion in the cardiac region far beyond the natural extent—and the strongly developed bruit de soufflet-rendered the diagnosis of the case quite clear. On questioning the mother as to the history of the case, I found it to be this. The little fellow had been seized at play with very sharp pain in the region of the heart, for which little was done beside keeping him in bed, no medical advice being considered necessary. There was not the slightest pain or swelling in any one of the joints. I catechised the mother very strictly as to this point, but always met with the same answer. I found, however, that a brother of the patient and older than him by a couple of years, had suffered, very nearly at the same time, from a severe attack of rheumatic fever which had confined him for more than a month to his bed, and that another brother, a little while previously, had suffered also in a similar way.-Here then was a case, as it seemed to me, in which acute rheumatism had fixed upon the heart, expending all its energy thereon, without invading any of the joints. In a family of strongly-marked rheumatic constitution, the essential elements, so to speak, of rheumatism which, in two of its members, had found in the joints "a local habitation and a name" had, in the other, made their seat solely in the heart and never strayed beyond its precincts in the form and with the character of rheumatic fever. Would other cases confirm this view? It was suggested to my mind by some that I had seen of which unfortunately I had never taken notes, but curiously enough I was led to take notes of the case that I have just narrated from its close resemblance, in nearly all its features, to one that I had seen but a little while before. A boy was brought to me, about nine years old, suffering from severe disease of the heart, but who had never had rheumatic fever, or pain or swelling in any of his joints. The history. of the case was precisely similar to that of the one that I have mentioned. He had been seized with very sharp pain in the left side-was quite unable to get about for days-and had afterwards more or less difficulty in walking—all of which symptoms were disregarded, till at last, at the end of three or four months, dyspnoea-palpitation-and anasarca induced the mother to seek my aid. From her report I learned that he had never had rheumatic fever, but that a younger brother had had it most severely. This case I never saw but once-but it made a strong impression on my mind-which was still more strengthened by the one that came immediately after, and which I also saw but once. Both patients died soon after I saw them, having been ill but a few months. Emma H, seven years and a half old, complains of pain in the region of the heart, which she has had more or less for the last six months-so severe, at times, as to rob her of sleep and prevent her getting about. On examining the chest, the heart is found to beat most violently-a strongly marked bruit de soufflet is heard accompanying the second sound-and there is dulness on percussion in the cardiac region over a much larger space than natural. In addition to the heart-disease, and perhaps connected with it, she has very decided symptoms of chorea, and moreover seems suffering from ascarides besides. The history of her case is this. Six months ago she was seized while walking with such sharp pain in the left side as obliged her at once to return home, where she was laid up for several days. From that time up to the present day the pain has been more or less severe, and her sleep and appetite have gradually failed till now her general health is much impaired. About six weeks before I saw her, or four months after she was first attacked, pain and swelling of the joints came on which confined her to bed for above a week. Both upper and lower extremities were attacked. Now that here was a case of cardiac disease originating in acute rheumatism of the heart would seem almost to be placed beyond a doubt by the subsequent affection of the joints. Dr. Watson, speaking of rheumatic carditis in connection with articular rheumatism, says"It is a curious circumstance that rheumatic carditis is sometimes the first step in the whole disease-the cardiac symptoms, I mean, precede those of the joints-even by two or three days." And then he gives an example.-But here was a case where the cardiac symptoms preceded the articular by at least four months: and might well make one think that rheumatic carditis may exist without any affection of the joints.-I gave Spigelia with the most marked effect in this case. The pain was instantly and thoroughly relieved, and the general health very much improved, but the chorea symptoms remained in statu quo--or at least did not show the same amendment as the others. Upon what do these depend-the cardiac disease? This case is one that I am treating still, and it is one that I shall watch with interest. The Rev. T. A. S. t. 50, is under my care, at the present time, for dropsy depending on disease of the heart, for which he consulted me nine years sgo. At that time all that he complained of to me were slight dull pains in the neighbourhood of the heart and "little convulsive struggles in the throat, on first falling asleep at night" On examining into the state of the heart, it was found to beat with hypertrophic violence-there was dulness on percussion in the cardiac region to a more than normal extent- and a decided bruit de soufflet was heard accompanying the second sound. Up to within the last six months he has not suffered much from this state of his disease, but recently, owing to fresh cause of aggravation, adema of the lower extremities came on, that has now invaded the abdomen. In this case, though I never was furnished with a history that satisfied me quite of its acute origin, there is reason, I think, to presume it was rheumatic-for though the patient never suffered from rheumatic fever, two of his family are completely crippled |