S'J-.'SvJ':- it-.'' ■*!«*' g?^fct. t-.V . . '■ *>*w'l:;'.';"'-'"," ■Us?.*- ^':i'; I isfC> j ***&✓ f ^ o l~S* 2 -fy NATIONAL LIBRARY OF MEDICINE l> f I f <3^ •P^) o- tor -v /f THE CYCLOPiEDIA OF PRACTICAL MEDICINE. VOL. IV. THE CYCLOPEDIA OF PRACTICAL MEDICINE: COMPRISING TREATISES ON THE NATURE AND TREATMENT OF DISEASES, MATERIA MEDICA AND THERAPEUTICS, MEDICAL JURISPRUDENCE, ETC, ETC. EDITED BY JOHN FORBES, M.D. F.R.S. PHYSICIAN TO THE QUEEN'S HOUSEHOLD, ETC. ALEXANDER TWEEDIE, M.D. F.R.S. PHYSICIAN TO THE LONDON FEVEK HOSPITAL, AND TO THE FOUNDLING HOSPITAL, ETC. JOHN CONOLLY, M.D. LATE PROFESSOR OF MEDICINE IN THE LONDON UNIVERSITY, PHYSICIAN TO THE HANWELL LUNATIC ASYLUM, ETC. THOROUGHLY REVISED, WITH NUMEROUS ADDITIONS, BY ROBLEY DUNGLISON, M.D. fROFESSOR OF INSTITUTES OF MEDICINE IN JEFFERSON COLLEGE, PHILADELPHIA, LECTURER ON CLINICAL MEDICINE AT THE PHILADELPHIA HOSPITAL, ETC. •* Hkc demum sunt que non subgessit phantasis imaginatricis temeritas sed phenomena practiea edocuere."—Sydenham. IN FOUR VOLUMES. PHILADELPHIA: BLANCHARD AND LEA. 1859. va- Entered, according to Act of Congress, in the year 1845, by LEA AND BLANCHARD, in tne clerk's office of the District Court of the United States for the Eastern District of Pennsylvania. 7AGAN, STEREOTYPER. COLLINS, PRINTER CONTENTS OF THE FOUETH VOLUME. Refrigerants. Rheumatism "} 23 Contributors. Page .Dr. A. T. Thomson .17 Barlow. Dunglison Rickets.............. Cumin....... 43 Roseola............. Tweedie...... 50 Rubeola............. Montgomery .. 51 Rupia............... Corrigan..... 58 Scabies.............. Houghton..... 59 Scarlatina............ Tweedie...... 67 Scirrhus............. Carswell...... 82 Scorbutus............ Kerr.........104 Scrofula ............ Cumin.......125 A.T.Thomson ~i ,.,. Dunglison .. 5 Sex, Doubtful........ Beatty.......153 Small-Pox........... Gregory......159 Softening of Organs... Carswell......175 Somnambulism and Ani- mal Magnetism..... Prichard.....194 Spermatorrhoea....... Dunglison .... 211 Spinal Marrow, Diseases of the............ Spleen, Diseases of the " Dislocation of the Sedatives R. B. Todd 213 ___223 Dunglison___229 Hawkins • • • ? 22g Dunglison .. ^ Williams.....237 A. T. Thomson.239 Statistics, Medical... < Stethoscope.......... Stimulants........... Stomach, Organic Dis- eases of the........ Houghton.....253 Stomatitis............ Dunglison ... .275 Strophulus........... Dunglison ... .276 Succession of Inheritance —Legitimacy....... Montgomery . .276 Suppuration.......... R. B. Todd ... 284 Contributors. Survivorship.........Dr. Beatty ... Sycosis.............. Cumin... Symptomatology...... M. Hall... Syncope............. Ash...... Tabes Mesenterica .... Joy...... Temperament........ Prichard . Tetanies............ Dwiglison Tetanus ............ Symonds . m. . t>- c,u C Tweedie .. 1 hroat, Diseases of the -2 „ ,. £ Dunglison Tissue, Adventitious ... Page ..290 ..296 ..298 ..329 ..333 ..349 ..363 ..364 ^376 390 Tonics.............. Tweedie......391 Toothache........... Dunglison___404 T°-»'^:.......{ ^Ln\:}^ Transformations...... Duesbury.....464 Transfusion.......... Kay.........468 Tubercle............. Carswell......474 Tubercular Phthisis ... Clark,(SirJas.)4:89 Tympanites.......... Kerr .-........570 Urine, Incontinence of . Cumin.......575 " Suppression of... Carter.......578 " Morbid states of the Bostock......581 » Bloody......... Goldie........588 Urticaria............ Houghton.....590 Uterus, Pathology of the Lee..........596 Vaccination.......... Gregory......620 Varicella............ Gregory......636 Veins, Diseases of the.. Lee..........639 Ventilation .......... Brown.......650 Wakefulness......... Cheyne......653 Waters, Mineral...... T. Thomson... 658 Worms............ Joy..........704 Yaws............. Kerr.........750 (5) K* fH£ CYCLOPiEDIA PRACTICAL MEDICINE. REFRIGERANTS (from refrigere, to grow cold), may be defined, medicines which diminish the morbid heat of the body. Their influence is generally admitted, but the theory of their opera- tion is not well understood ; and, consequently, many and very opposite hypotheses have been ad- vanced upon the subject. The first of these which deserve notice is that of Cullen, based upon a doctrine of Needham ; it forms a remarkable in- stance of the obscurity into which hypothesis leads men otherwise distinguished for the perspicuity and soundness of their reasoning. This hypothe- sis supposes " that there is every where, in nature, an expansive and a resisting power; and that, particularly under a certain degree of heat, the expansive power appears in all the parts of organ- ized bodies, in consequence of which they show a singular vegetating power; while, at the same time, there is, in other bodies, a power resisting and preventing the action of this vegetating power, and, at least, of diminishing its force." And it is assumed that this power is found in those sub- stances which are usually employed as refrigerants. (Mat. Med. ii. 121.) It is unnecessary to com- ment upon these opinions ; indeed, their obscurity is such as to render them scarcely intelligible. A later theory is that of Dr. John Murray, whose habit of reasoning upon chemical princi- ples led him to call in the aid" of these to explain the operation of refrigerants. He founds his opi- nion on the presumption of the truth of the theory of Dr. Crawford, that, in the process of respira- tion, the arteries in the lungs absorb the caloric liberated there; and, owing to the great capacity of arterial blood for caloric, they instantly render it latent, in which state it remains until the subse- quent conversion of the arterial into venous blood, when it is liberated equally through the system. Now, Dr. Murray considers that the consumption of oxygen in the lungs, supplying the caloric to the arterial blood, is greatly influenced by the na- ture of the food and other ingesta received into the stomach. He supposes that when these substances contain a small proportion of oxygen, the demand for that component of the air, and its consumption by the lungs, are augmented ; and, consequently, the animal temperature is elevated; whereas an opposite effect takes place when the ingesta con- tain much oxygen, more especially if it exist in a loose state of combination. According to this theory, therefore, all substances containing much oxygen capable of being extricated by the powers Vol. IV. —3 b* of the stomach, should possess a refrigerant influ- ence. Plausible as this theory appears to be, its accuracy is very questionable; but, in order to reason correctly upon its merit, it is necessary to take a cursory view of the theory of animal heat upon which it is founded ; for if the difference of capacity of arterial and venous blood for caloric be insufficient to account for the temperature of the living body, Dr. Murray's theory of the changes produced by refrigerants must necessarily fall to the ground. Dr. Crawford's object was to prove, as already stated, that arterial blood has a greater capacity for caloric than venous blood ; and this is also the case in reference to common or atmospherical air and carbonic acid gas. The latter fact explains the augmentation of temperature arising from the change which the air undergoes in the lungs when carbonic acid is present in them ; but as the caloric thus evolved is absorbed by the arterial blood, and rendered latent, the sensible temperature of the blood is not augmented; and it only becomes so as the arterial blood changes to venous in the course of its circulation. By this evolution of caloric the loss of temperature which the body sustains is compensated. Respiration, therefore, and the greater capacity of the arterial than the venous blood, are, according to this theory, the true sources of the peculiar temperature of the living body. Many facts might be mentioned as favouring the truth of Dr. Crawford's hypothesis ; for example, the greater the comparative size of the lungs, and the greater the quantity of blood which passes through them, the higher is the temperature of the animal. Thus, the capacity of the lungs is greatest in birds, which have the highest temperature among animals ; and it is a well-known fact, that what- ever lessens the free action of the lungs and dimi- nishes the consumption of oxygen, reduces the temperature of the animal. Individuals who la- bour under a malformation of the heart sufficient to prevent the arterialization of the blood, are always of a temperature below the natural stand- ard. In hybernating animals, also, the tempera- ture falls as the respiration is suspended; and it rises with the return and the progress of respira tion: and, farther, M. Gallois ascertained, by ex periment, that the temperature of the body falla exactly in the ratio of any diminished quantityol oxygen consumed in respiration. These opinions are strengthened by some experiments of Dr. Wil- '17 18 REFRIGERANTS, son Philip ; and, upon the whole, it is tolerably well ascertained that the temperature of the body sinks, if it be not maintained by the chemical changes which occur in respiration. But, notwithstanding the support thus given to Dr. Crawford's opinion, many and as strong facts have been advanced in support of that view of the subject which regards nervous energy as the source of animal heat. The most important ex- periments on this side of the question are those of Mr. [Sir B.] Brodie. He found that, by maintain- ing the action of the heart by artificial respiration after the brain is removed, although the blood undergoes its ordinary changes, yet that the tem- perature of the animal thus treated is rapidly lowered. Sir B. Brodie's experiments were made on rabbits, in which the functions of the brain were suspended by dividing the spinal marrow: the blood, in both systems, underwent no change different from that which occurs in natural res- piration. " It may perhaps be urged," says Sir B. Brodie, "that, in these experiments, the secre- tions had nearly, if not entirely, ceased : it is probable that the other changes which take place in the capillary vessels had ceased also, and that, although the action of the air on the blood might have been the same as under ordinary circum- stances, yet there might not have been the same alteration in the specific heat of the fluid as it flowed from the arteries into the veins. But, on this supposition, if the theory of Dr. Crawford be admitted as correct, there must have been a gradual but enormous accumulation of latent heat in the blood, which we cannot suppose to have taken place without its nature having been en- tirely altered. If the blood undergo the usual change in the capillary system of the lungs, it is probable that it must undergo the usual change in the capillary system of the greater circulation also, since these changes are obviously dependent on and connected with each other." From the experiments of Sir B. Brodie it appears that, when the functions of the brain are suspended, the power of generating animal heat is also sus- pended ; although the same quantity of oxygen be consumed as in natural respiration under ordi- nary circumstances. It is, nevertheless, proper to mention here the opinion of M. Le Gallois, that, owing to the nature of artificial respiration, upon which Sir B. Brodie's conclusions are founded, the temperature may fall, and the animal be killed by cold, although every part remain uninjured. The air in artificial respiration does not enter the pulmonary cells in the same manner as in natural respiration, but is forcibly propelled into them; a large formation of frothy mucus occurs, which both prevents the air coming in contact with the lining membrane of the air-cells, and by its eva- poration tends to cool the body. Many other facts concur, also, to prove that the temperature of the body is regulated by the nervous energy. It is true that these demonstrate its effect chiefly in mail..amine; the heat of parts; but if its influence on parts be admitted, it is not easy to conceive on what grounds its power over the entire system can be denied. Sir Everan' Home divided the nerves going to the growing antler of a stag, and found that the temperature almost immediately fell; and although, after a few days, it rose again higher than before, yet this may have originated from the reunion of the divided nerves : at all events it does not invalidate the fact that the temperature fell on the division of the nerves, and, consequently, was regulated by their condition. In paralyzed limbs the tem- perature sinks, although in many cases the circu- lation in the limb is unaffected, and the paralysis is confined to the sensibility of the member. In a case recorded by Mr. Earle, in which the axil- lary plexus of nerves on one side was crushed, the paralyzed limb of that side was of a lower temperature than the opposite limb: indeed, in general we find that increased nervous action, whether depending on affections of the mind or on other causes, augments the heat of the body ; whilst the effect of depressing passions, which diminish nervous energy, is followed by either general chilliness, or coldness of the extremities. These facts undoubtedly go far to prove that animal heat is a vital principle closely connected with the integrity of the nervous system ; hut at the same time, as the stimulus of arterial blood is requisite for the excitement of the brain and nerves, and arterialization is the result of respira- tion, the influence of respiration in the production of animal heat must be so far admitted; for with- out the function of the lungs the brain would lose its energy, and the temperature of the system be necessarily greatly lowered. This opinion re- ceives also considerable support from some ex- periments of Dulong to ascertain whether the quantity of caloric, developed by the consumption of oxygen in respiration, be equivalent to the quantity given out by the body. He found that in carnivorous animals the proportion is equal to forty-nine and fifty-five parts in one hundred of the heat generated by the whole body during the same interval of time ; and, in phytivorous ani- mals, to betwixt sixty-five and seventy-five parts; and that the whole quantity of caloric and water together is equivalent to sixty and eighty parts only ; so that the animal heat is greater than can be accounted for by the fixation of oxygen during respiration. Upoa the whole, the examination of both sides of the question leads us to conclude that both opinions are to a certain extent true; that animal heat is influenced chiefly by the state of the nervous system, but partly, also, by the chemical changes which take place in the lungs during respiration. [See, on all this subject, the physiological works of Miiller, Carpenter or Dun- glison.] If this view of the sources of animal heat be correct, it presents a considerable obstacle to the admission of Dr. Murray's explanation of refrige- rants, which can only be regarded in the light of an ingenious hypothesis. The subject, therefore, remains as he found it; and the question presents itself—can no rational explanation of the opera- tion of refrigerants be suggested 1 The writer of this article, although he does not venture to offer a theory likely to be generally adopted, yet con- ceives that some approach to a rational explana- tion may be attained by ascertaining how far the a. tion of refrigerants taken into the stomach re- sembles that produced on the skin by similar substances. In abstracting caloric from the surface of the REFRIG body, or, in other words, cooiing the skin, what- ever agent be employed, whether diluted acids, salts in a state of solution, cold air, or cold water or ice, the activity of the capillaries of the part is immediately diminished ; and as their action can- not be materially lessened without the whole vas- cular system being more or less influenced, the vigour of the heart and arteries is also materially depressed. The consequence of this diminished vascular action is immediately felt on the respira- tion ; the blood does not undergo its necessary change ; venous blood is conveyed to the brain, the function of which being impeded from defect of stimulus, a state somewhat resembling para- lysis of the nervous system ensues, so that torpor of every organ, the function of which depends on the energy of the brain and nerves, must neces- sarily follow. The effect of the abstraction of caloric on the nerves is strikingly illustrated by the numbness and insensibility which follow the exposure of the hands, in many individuals, in cold weather; a result which is more likely to arise from the direct influence of cold on the nerves themselves, than from the diminished supply of blood to the parts. Indeed, as in this case the effect on the nerves is partial, we can scarcely imagine any other cause of the diminished action of the capillaries than the depression of the nervous energy. Now if we suppose,—and the supposi- tion is far from being unreasonable,—that an effect resembling that produced on the surface takes place in the stomach when refrigerant agents are introduced into it, we may readily admit that the effect on the capillaries of that organ is extended by sympathy over the system. The possibility of such a result is equally probable in the one case as in the other. This opinion receives some support from the fact that nitrate of potassa operates as a powerful general refrigerant when it is swallowed at the instant of its solution ; but it acts as an excitant when it is not taken into the stomach until after it have been some time dis- solved. The sensation of cold which the nitre, during solution, causes in the stomach, is evi- dently owing to a partial abstraction of stimulus, and the effect of this being extended through the nerves to the heart and larger branches of the arterial system, a general reduction of action is produced, and this is followed by a sensation of cold over the whole body. Let us now inquire how far this theory is borne out by the known effects of refrigerants upon the functions of the stomach, the lungs, and other organs. 1. In the healthy condition of the stomach, re- frigerants exert little perceptible influence upon it; but when it is either in an irritable state, or affected with inflammation, the continued use of refrigerants, particularly cold and iced water and lemonades, allays the sensation of heat, nausea, and general uneasiness. Even when no local in- flammation exists, cold water and other cold, bland fluids, received into the stomach, moderate general excitement and control febrile action ; an effect which can only be explained by the influence of the refrigerants on the nervous energy. The same results follow the administration of refri- gerants in enteritis. 2. Refrigerants exert no evident influence on tne circulating and respiratory organs, in the GRANTS. 19 state of health; although in some individuals, owing to idiosyncrasy, acidulated fluids cannot be taken without so powerfully affecting the larynx as to cause a temporary loss of voice; but in a diseased state of these organs the influence of refrigerants is well marked. In an excited state of the vascular system, when the pulse is both quicker and stronger than natural, acidulated drinks reduce both states, both moderating the action, and relaxing the tension of the pulse; nor is their effect on the capillaries less manifest; and it is to their influence on these that we must attribute the diminished tempera- ture which follows their administration. It is surely unnecessary to say how intimately this is connected with their impression on the nerves of the stomach. In the febrile state, the effects of refrigerants on the circulation are necessarily com- municated to the lungs; but besides this sympa- thetic influence, some of this class of medicines, in particular, acids, seem to operate directly on the pulmonary tissue. In acute inflammation of the air-tubes, or even of the pleura, acid fluids greatly augment the cough and oppress the breath- ing, when administered before the excitement be subdued ; and after this is effected, we still per- ceive the evidence of their action on the mucous membrane by the aid which they afford to ex- pectoration. 3. But the most decisive illustration of the extent to which the nervous system is influenced by refrigerants, is observed in the effects which acidulated fluids produce on those who are la- bouring under diseased conditions of the spinal cord. The author had an opportunity of wit- nessing this in a gentleman who was labouring under subacute inflammation of the spinal theca. Whenever he swallowed a spoonful of lemonade, or even an ordinary effervescing draught, a sensa- tion of pricking was felt over the surface, the skin became so sensitive as scarcely to admit of being touched, and the whole system restless and un- easy. Hypochondriacal and hysterical persons, not unfrequently, suffer in a similar manner from the internal use of acids ; and, as this effect is not confined to particular individuals, it cannot be ascribed to idiosyncrasy. Upon the whole, it is evident that refrigerants operate to a certain extent as sedatives ; diminish- ing the force and rapidity of the pulse, depressing morbid temperature, and calming, generally, the disturbance which always attends acute diseases. The substances employed as refrigerants operate either on the organic functions or on the sensi- bility of the body in a state of disease. 1. The refrigerants operating on the organic functions are chiefly vegetable acids. The in- fluence of acetic acid, in its diluted impure state or as vinegar, in cooling the body labouring under disease, was very early known. In its undiluted state it is a powerful stimulant; and when daily taken in large doses into the stomach in its diluted form, it produces great uneasiness, cramps, and colic, and gradually destroys so effectually the texture of the organ and its digestive function, as to cause emaciation of the body. When it is only occasionally taken, largely diluted with wate* and moderately sweetened, it displays decided soothing and refrigerant properties, and is em 20 REFRIGERANTS. ployed with advantage in inflammatory and bilious fevers, for quenching thirst, calming the vascular excitement, re-establishing the perspiratory func- tion of the skin, and restoring the action of the kidneys. In inflammatory affections of the lungs, however, it increases the cough, and augments the morbid sensibility of the mucous membrane in the same manner as all other acids; and, therefore, it is contra-indicated in such diseases, even as an expectorant, until the excitement be subdued. The refrigerant influence of diluted vinegar on the surface is undoubted ; it not only diminishes heat but allays pain. In hemorrhagic affections, the cold feeling which it produces on the skin is extended to the whole system ; hence the benefit derived from it in internal hemorrhages, and in the inflammation of cavities; as, for instance, in uterine hemorrhages applied to the thighs and ab- domen ; and in acute meningitis applied as a lotion to the shaved scalp. In general fever, sponging the body with vinegar and water is ap- plicable to every case in which the skin is preter- naturally hot, when no idiosyncrasy stands in the way. When diluted acetic acid is internally admi- nistered, if opium be prescribed at the same time, it should be recollected that it decomposes the meconate of morphia of the opium and forms an acetate, which is a more powerful narcotic than the meconate. The combination of this acid with ammonia, in the prepaiation known by the name liquor ammonia: acelatis, possesses refrigerant powers nearly equal to those of the diluted acid, acting at the same time as a diaphoretic ; and it is more generally employed than the acid in mo- dern practice. The salts procured by the com- bination of acetic acid with the other alkalies operate chiefly on the kidneys. The citric acid is more frequently employed than the acetic as a refrigerant; hut chiefly in its combined state as prepared by the hand of nature, in the juice of the lemon, the orange, and other fruits. It is more grateful in its combined than in its uncombined state; a fact which is quickly perceived by patients in fever, when it is ordered to form the common effervescing draught for checking nausea and vomiting. When simply diluted with water, in the proportion of the juice of two moderately-sized lemons to a pint of water, and slightly sweetened, forming lemonade, citric acid constitutes a most serviceable and agreeable beverage in fevers ; and in those of a typhoid character this is rendered more grateful and bene- ficial by using water impregnated with carbonic acid gas instead of common water. In the ordi- nary condition of the stomach, citric acid, either pure or combined, does not weaken the stomach; and in some irritable states of that organ, charac- terized by a sensation of heat, painful digestion, an unpleasant taste in the mouth, and a disgust of food, it removes these symptoms and proves decidedly beneficial: but on the other hand, when the stomach is highly irritable, and its nervous susceptibility great, lemon-juice, or the citric acid, even when largely diluted, causes heat, uneasi- ness, and pain, and not unfrequently obstinate vomiting. Nevertheless, as M. Broussais has remarked, (Phlegmas. Chron. t. iii. p. 254,) the citric acid is that which the stomach supports bes when suffering under inflammation. The citrates of potassa and of ammonia are also refrigerant; the citrate of soda, which is not an officinal preparation, operates as a purgative. The above remarks are applicable to the juice of the orange, the apple, the currant, and the gooseberry, all of which owe much of their acidity to the citric acid. _ . The tartaric acid, except as it is contained in the tamarind, is much less frequently prescribed than the citric as a refrigerant, being more apt to disorder the digestive organs, to produce colic and to purge; and its morbid influence on those labouring under affections of the spine is more constant and evident than that occasionally re- sulting from the employment of citric acid: indeed, so obvious is this, that patients sometimes refuse to continue taking it on account of the nervous agitation which it causes. Its combination in the form of the bitartrale is more frequently em- ployed ; and in small doses at moderate intervals, it does not operate as a purgative, but as a simple acidulous refrigerant. It is best administered in the form of whey, or of cream-of-tartar beverage; it moderates febrile heat and softens the skin; but when its employment is followed by a red and dry tongue, it ought to be discontinued. Both the acid and the bitartrate are incompatible in mix- tures with the nitrate of potassa, which it decom- poses, and, uniting with its alkaline base, forms either a bitartrate or a tartrate. The oxalic acid in the form of the binoxalate, as found in the oxalis acetosella and rumex ace- tosa, was formerly much prescribed as a refrige- rant ; but these plants, and, indeed, the oxalic acid in any form, are now rarely employed. Nitrate of potassa, in small doses, is a well- known refrigerant: it produces a powerful sym- pathetic effect on the nervous system, depressing the strength and diminishing the frequency of the pulse, and lowering the animal heat: the skin becomes pale, and a sensation of languor is felt. To obtain the full refrigerant effect of nitre, the salt must not only be administered in small doses at short intervals, but it should not be dissolved until the instant in which it is to be administered. As a refrigerant, the dose should not exceed a scruple, or, at the utmost, half a drachm. The bicarbonate of soda, although seldom pre- scribed as a general refrigerant in this country, yet is frequently administered in inflammatory febrile affections on the continent. It is, however, better calculated for operating as a local than as a gene- ral refrigerant. 2. The refrigerants operating on the sensibility of the body are few ; but they are more directly refrigerant than those which have been already noticed. Cool air, the first of these, is so agree- able to the feelings in a heated state of the body, that observation alone might have led to its early employment as a remedial agent; and nothing marks more strikingly the perversity of mankind than the opposition of physicians, at one period to the indulgence of the instinctive desire for this remedy in fever patients. Its utility in moderating high vascular action and operating as a sedativa refrigerant is now generally acknowledged; and REFRIGE consequently its admission to the apartments of the sick, in febrile diseases, is almost universal. If cool air be beneficial in the above-mentioned conditions of the body, cold water and ice are still more so ; and their application is extensive. For an account of the effects of cold water and ice in reducing the temperature of the body in its healthy condition, we must refer our readers to the articles Bathtxg and Cold. When cold water and ice are employed as curative agents, their influence may be obtained either by their internal adminis- tration or by their application to the surface ; in , both cases their effects are extended by sympathy over the system; but they are modified by the manner in which these agents are used. If the body be immersed in the cold bath, the most striking effect is the shock or nervous impression which produces the vascular reaction so beneficial when cold bathing is used as a tonic ; an effect, however, which must be avoided as much as pos- sible when the refrigerant influence only of the bath is required. To insure simple refrigeration, the water should be of a temperature not much below that of the skin; but as, even at such a de- gree of heat, the sudden immersion of the body is likely to cause more reaction than would be safe in cases requiring mere refrigeration, the cold bath is rarely or never employed in this country for producing that effect. The shock and reaction caused by dashing cold water over the body, con- stituting the cold affusion as it is termed, is as considerable as when the cold bath is used, but it is more transitory, and therefore it is a more use- ful refrigerant. Sponging the body with cold water, as far as a simple refrigerant effect is de- sired, is preferable to either the cold bath or the cold affusion : there is no shock ; the fluid, being left to evaporate, merely cools the surface ; and by persevering in the process, the cooling effect is fully obtained, and rendered permanent. One great advantage of sponging the surface with cold water is the facility of limiting the extent of the effect according to the feelings of the patient: in general it may be continued until the sensation of chilliness comes over the body, when the patient should be dried and placed in bed. The more simultaneously the influence of cold water is ex- tended over the surface, the better; the process of sponging should, therefore, be performed by several attendants with large sponges on the dif- ferent parts of the body at the same time. In ordinary cases the temperature of the water may be regulated by the feelings of the patient, as the beneficial effect depends on the evaporation, which may be aided by the addition of vinegar or alcohol. Evaporating lotions applied to a part, operate locally in the same manner as general sponging; the sedative and refrigerant influence is not con- fined to the part, but extends to other parts of the body, even to the interior, as, for instance, to the brain, the contents of the abdomen, and to joints. The sedative effect is still more powerful when a small stream of cold water is directed upon the part: the author of this article has seen this most strikingly exemplified in burns ; the mere immer- sion of the part in cold water, or the application of cloths dipped in cold or even iced water, is much inferior in its effect to this method of em- ploying cold water. It is scarcely necessary to I R A N T S. 21 comment on the influence of the local application of ice, which operates exactly in the same manner as evaporating lotions, but more effectively, owing to the steady continuation of the same low tempe- rature to the parts. The foregoing remarks lead to this conclusion— the utility of refrigerants as curative agents is more limited than that of most other classes of remedies. They are chiefly employed to depress inordinate vascular action, and thereby to lower temperature ; consequently, it is in inflammation, active hemor- rhages, and febrile affections that they are found beneficial; and in such cases they are, undoubt- edly, most valuable remedies. In local inflammations on the surface of the body, cold water and evaporating lotions prove highly serviceable; whilst in those more deeply seated, as, for instance, inflammation of the brain and its membranes, ice applied to the scalp is to be preferred : the steady abstraction of caloric which it effects, operates not only upon the vessels and nerves of the integuments, but, by diminish- ing action in the carotids and large vessels, it pro- duces the most decisive benefit in reducing the vascular action within the cranium. These ap- plications have been lately recommended in other internal inflammations, even those of the thorax and abdomen, and under proper circumstances have been found highly beneficial. Hemorrhage arising from increased action, or accompanied by it, is frequently checked by the sedative influence of refrigerants. When the bleeding is internal, the degree of,cold should be such as to operate sympathetically on the whole system; and to lessen not only the action of the vessels of the part, but to restrain, to a certain de- gree, that of the heart. Thus in hsemoptysis, not only should the patient be freely exposed to cold air, but ice and cold acidulous fluids should be freely administered ; indeed, the temperature may be with safety, and even with advantage, dimi- nished so much as to be uncomfortable to the feelings of the patient. In such a case, the low degree of temperature is accompanied with an evi- dent diminution of the irritability of the contrac- tile fibres of the whole vascular system, and, con- sequently, aids greatly in checking the flow of blood. The liquids administered as drink should be cooled down to 32°, either by ice or by a freezing mixture, and slowly swallowed. The in- fluence of nitre has long been regarded as con- siderable in such cases ; and much of the benefit received has been attributed to a chemical change effected on the blood ; but if the opinions advanced in this article be correct, it is unnecessary to assert that this explanation of the operation of nitre must fall to the ground. [The notion of nitrate of potassa being refrige- rant has probably arisen from the coldness which it occasions whilst undergoing solution in water. Indeed, as elsewhere stated, (General Therapeutics, Philad. 1836, and General Therapeutics and Ma- teria Medica, ii. 206, Philad. 1843,) all internal refrigerants probably act wholly by their being comparatively of low temperature, and thus re ducing the heat of the stomach. A recent writer, Dr. Spillan, (Manual of General Therapeutics, p. 185, London, 1841,) after citing the published opinion of the writer on this subject, states that REFRIGERANTS. " the refrigerant effects of nitrate of potassa as a sedative, when given dissolved in even tepid drinks, such as whey, are known to every one." They certainly are not known to the writer; yet he has watched most carefully for them; nor have others been more fortunate. Dr. A. T. Thomson says, that " the dose of the salt should not be dis- solved until the instant in which it is to be swal- lowed," (Elements of Mat. Med. and Therap., 2d edit. Lond. 1835) ; and Dr. Pereira (Elements of Mitt. Med. and Therap., Amer. edit. i. 438,) ac- cords with him ; whilst Dr. Christison (Dispen- satory, p. 741, Edinb. 1842,) expresses himself in a manner that still more strongly corroborates the views of the writer:—" Its refrigerant action, gene- rally admitted by systematic writers on materia medica and by many practitioners, is of doubtful existence, having probably been inferred rather from the coldness it occasions while dissolving in water, than from actual evidence of its effects in disease. The sedative action ascribed by some to it has been probably inferred from its supposed re- frigerant property, and not from observation."] In hsematemesis occurring in young and vigo- rous perons, the same assiduous employment of refrigerants is requisite as in haemoptysis; and when the bleeding is so violent as to threaten quickly serious consequences, the other refrigerant plans may be aided by injecting iced water into the rectum, and by the local application of cold to the epigastrium. In no species of hemorrhage is the sympathetic influence of refrigerants more strikingly obvious than in epistaxis. Thus dash- ing cold water on the genitals has sometimes in- stantaneously suppressed bleeding at the nose; and on the same principle is explained, what it is scarcely necessary to notice, the popular remedy of applying a large cold key or a piece of metal between the shoulders under the clothes. It is superfluous to say that, however useful refrigerants may prove in all cases of active he- morrhages, their employment in the passive is to be most carefully avoided. But it is in fevers that refrigerants under every form are to be regarded as the most valuable set of therapeutical agents. In continued fever, the vegetable acids largely diluted are internally administered, especially those found in fruits; and not unfrequently nothing is more grateful to fever patients than cold water slightly acidulated with either the sulphuric or the nitric acid. It is, how- ever, the general application of cold to the surface which proves the most useful refrigerant in con- tinued fever. In those forms of the disease which assume a typhoid type, ventilation and the free admission of cool air into the apartments of the sick are absolutely necessary: irritation is allayed, debility obviated, and the whole complexion of the disease often changed in a few hours, by the removal of the patient into a cool and well-venti- lated, from a close and filthy apartment. The most direct and effective refrigerant, however, in continued fevers is the cold affusion; but its employment requires certain cautions, without at- tention to which much mischief may be incurred. In the first place, the exact temperature of the body must be carefully ascertained. In this country, ir. the severest attacks of fever, it has »«reh exceeded 108° Fah.; but in tropical climates it rises sometimes to 112°; the highe the temperature of the patient, the more beneW may be anticipated from the cold affusion, me temperature of the water should vary according to the season of the year and the feelings of the patient, the average range being from 40 to 70 Fah. The effect is to diminish the morbid heat of skin, to lower the force and retard the rapidity of the pulse,and to induce perspiration and sleep; and when such results follow, the cold affusion proves beneficial in any form of fever. The thermometer is employed to determine the temperature of the patient; but if he feel cold when that instrument indicates an augmented morbid temperature; or if he feel hot when the thermometer demonstrates that the heat of the body is below that of the natural standard ; then in neither case should this form of refrigerant be resorted to. It is also improper when the skin is bedewed with perspiration ; or if the patient dread greatly its use; nor is it less so during menstrua- tion, and in the latter months of pregnancy. In the advanced stages of fever, refrigerants of any kind are injurious. With respect to the kinds of continued fever in which refrigerants are indicated, we may enumerate six. 1. In inflammatory fever, (synocha,) a Tare dis- ease when unaccompanied with topical inflamma- tion, the advantages to be derived from refriger- ants are well understood. The cold affusion is admirably adapted for rapidly abstracting the stimulus of heat, diminishing general excitement, and operating as a powerful sedative. In the more advanced stages of the disease, cool spong- ing is often substituted for the affusion ; but when the patient can bear the fatigue of the affusion, it is always to be preferred. The greater frequency of this form of fever among the ancients than the moderns explains their constant employment of cold drinks and cold bathing in continued fever. 2. In fevers of a typhoid type, the disease has been cut short by the cold affusion ; but in this case more perhaps is to be attributed to the shock and the reaction which follows, than to the refri- gerant influence of the affusion. 3. In synochus or inflammatory fever, gradually assuming the typhoid character, refrigerants in general, but more especially the cold affusion, are chiefly applicable to the early stages of the disease; and, indeed, no form of remedy is more advanta- geous when there are no local determinations; but when these exist, particularly if the lungs be affected, much caution is required. 4. In remittent fevers, especially those of warm climates, and in their more intense and excited variety, the cold affusion may be employed with great benefit. In severe attacks, also, much advantage is derived from the application of ice or cold water to the scalp ; in the remissions, how- ever, the application of cold in any form must be suspended. In yellow fever, the safety of the patient frequently depends solely on the early ap- plication of the cold affusion. 5. If hectic be symptomatic of pulmonary af- fections, or determination to internal organs the cold affusion is decidedly contra-indicated •' but even in such cases much benefit is often obtained by sponging the trunk of the body with cold REFRIGERANTS — RHEUMATISM. 23 water mixed with vinegar, whilst the lower ex- tremities are kept warm in bed. We must, never- theless, bear in mind that, under any form of hectic, although general refrigerants are useful auxiliaries, yet the cold affusion can scarcely be regarded as admissible. 6. In most eruptive fevers, except measles, the body should be freely exposed to cool air ; and even the cold affusion may be safely and advan- tageously prescribed, should the state of the sur- face require it, nor should the presence of the eruption operate as a reason against its employ- ment. The Hindoo physicians plunge their patients, during the eruption of small-pox, into cold water, and with the best results. It dimin- ishes the fever, lessens the number of the pus- tules, and is said to prevent pitting. The writer of this article has long been in the habit of em- ploying the cold affusion in scarlatina during the height of the eruption, and has seen the severity of the disease instantly checked by it. In intermittent fevers, when the skin is dry and parched, and the general heat greatly augmented, cold in every form applied to the surface, and cold acidulated fluids taken into the stomach, are of the same value as in continued fever, and greatly favour the accession of the sweating stage. The affusion should be used in the hot stage of the paroxysm, and continued until the temperature of the body of the patient be reduced to the natural standard. It is unnecessary to discuss the nature of the various diseases, besides idiopathic fevers, in which refrigerants are indicated : in all, much depends on the degree of the attendant fever, and the ex- istence of local affections. In one local disease, phrenitis, however, their advantageous effects are very conspicuous: the most furious delirium is quickly subdued by allowing cold water to drop on the vertex, whilst the rest of the scalp is cov- ered with cloths moistened with vinegar and water. The degree of collapse, indeed, which is thus produced, is often so great as to require most active measures to counteract it; when such occurs, the state of sinking is to be treated exactly in the same manner as when extreme debility suddenly appears from other causes: external warmth, particularly the application of bladders of hot water to the scrobiculus cordis, friction, electricity, and sometimes artificial respiration, are the means to be employed to restore animation ; and when the power of deglutition returns, the administration of excitants, especially aromatics and ammonia, is to be resorted to. From the foregoing remarks, it is evident that, although, as we have already said, refrigerants constitute a class of medicines of limited applica- tion, yet they are of much value in a few impor- tant diseases. Like every other class of thera- peutical agents, their utility will be more or less obvious as the discrimination, the judgment, and the observation of the practitioner are properly exercised, in determining the exact condition of the body which demands their employment. A. T. Thomson. RHEUMATISM, from ^ttya, a dejluxion. This tprm, originally adopted when diseases ac- companied with swelling were usually attributed to the flow of some special humour to the part affected, has been used for ages to designate an affection which has so much of distinct character as to justify its being considered a special dis- ease. So loosely, however, has the term been applied, that a host of ailments, with no character in common save that of pain, have been classed under it, and much both of false experience and of bad practice has thence resulted. Diseases called rheumatic have been relieved by stimulant remedies, which from the character thus acquired have been empirically resorted to in states of con- stitution for which they were utterly unsuited. In acute rheumatism, a disease intensely inflam- matory, we have known the use of the most pow- erful stimulants confidently urged by well-meaning but misguided friends, who in support of their prescription have pleaded the wonderful cures which they had seen their favourite specific per- form in what they assumed to have been rheuma- tism ; thus misled by a name to recommend in active inflammation what could have benefited only in a totally opposite state of the system. As many affections really rheumatic present an equi- vocal character which to superficial observation too often appears to justify the use of stimulants, it is very necessary to discriminate the real dis- ease, so as to distinguish it from those diseases with which it is liable to be confounded; and however difficult it may be to class the latter, it is better to leave their place in nosology unassigned, than, by ranging them under the head of rheuma- tism, to beget confusion where clearness and pre- cision are of the first importance. In the investigation of rheumatism, the best mode, similar to what was followed in treating of gout, is to consider, first, the simple disease in its most perfect form ; and then, with the lights thus supplied, to elucidate the more complex conditions which the larger portion of rheumatic affections present. So contradictory, and, we may add, so ineffectual are the means ordinarily used in treat- ing the latter, that no greater benefit could be con- ferred both on patients and practitioners, than to divest the treatment of perplexing confusion and inconsistency by reducing it to fixed principles, and bringing it within the pale of rational and scientific practice. In determining the diseased condition to which the name of rheumatism should be specially as- signed, it is expedient to examine the representa- tions given of it by the systematic nosologists. Sauvages describes rheumatism as « dolor diutur- nus in parte carnosa artuum," and places it in the class Dolores, order Vagi, of his nosology. Ac- cording to Linnaeus, it is "musculorum dolor ad motum, a tunica cellulosa injecta;" class Dolores, order ExtrinseciJ" Vogel places it in class Dolores, as merely " cutis et musculorum dolor." It would be difficult to recognise in these brief and meagre specifications the ordinary disease of rheumatism, such as we daily witness it. Sagar is both more copious and more precise. He describes two diseases, a chronic one ranged in the class Dolores, order Vagi; and an acul>-.' under the specific name of myositis, in the class Phlegmasia, order Phlegmasia: musculosse, giv- ing respectively the following definitions. " Rheu- matismus. Dolor Diuturnus in parte carnnsu 24 RHEUMATISM. tendinosa artuum, vagabundus, saepius sine coryza, rheumate, catarrho, erysipelete, et sine febre nota- bili; (acutus rheumatismus facit genus inter Phleg- masias, myositin a me dictum;) sanguis missus rheumatismo laborantium, est gelatinosa crusta tectus, et urina saepe ad sulphureum colorem ten- dit." " Myositis. Febris acuta inflammatoria, dolores in diversis musculis artuum, eorundemque involucris, diu noctuque discruciantes, motum ve- tantes fere omnem, ad noctem exacerbantes ; san- guis missus est tectus crusta inflammatoria subge- latinosa, vel pelli tenui tenaci: hie morbus vulgo audit rheumatismus acutus." It is worthy of re- mark that Sagar notices the blood drawn in chro- nic rheumatism as exhibiting a buffy crust. Cullen considers acute rheumatism alone as a special dis- ease, regarding the chronic form as only a sequel of it. He places it in the class Pyrexia:, order Phlegmasia:, and gives the following definitions. " Rheumatismus. Morbus ab externa et plerum- que et evidente causa ; pyrexia ; dolor circa arti- culos musculorum tractum sequens, genua et reli- quos majores, potius quam pedum vel manuum articulos infestans, calore externo euctus." " Rheu- matismi sequela est, Arthrodynia. Post rheuma- tismum, nisum violentem vel subluxationem, do- lores artuum vel musculorum, sub motu prsesertim aucti, plus minusve fugaces, calore lecti vel alio externo levati; artus debiles rigidi, facile et ssepe sponte frigescentes; pyrexia nulla; tumor ple- rumque nullus. Rheumatismus chronicus aucto- rum." I.— Acute Rheumatism. This disease is often designated by the trivial name of rheumatic fever, a term which implies a constitutional disturbance as well as a local. The ordinary phenomena which characterize it are so familiarly known, that a very brief account of its accession and progress will here suffice. That given by Sydenham, derived as it was from actual observation, and marked by his wonted truth and accuracy, presents in few words as clear a descrip- tion of the early seizure as can well be rendered. " This disease happens at any time, but espe- cially in autumn, and chiefly affects such as are in the prime of life. It is generally occasioned by exposing the body to the cold air immediately after having heated it by violent exercise, or some other way. It begins with chilliness and shiver- ing, which are soon succeeded by heat, restless- ness, thirst, and the other concomitants of fever. In a day or two, and sometimes sooner, there arises an acute pain in some one or other of the limbs, especially in the wrists, shoulders, knees ; which shifting between whiles, affects these parts alternately, leaving a redness and swelling in the part last affected. In the beginning of the illness the fever and the above-mentioned symptoms do sometimes come together, but the fever goes off gradually, while the pain continues, and some- times increases." The latter circumstance Sydenham, in con- formity with the pathology then prevalent, attri- butes to the " derivation of the febrile matter to the limbs," which he conceives to be sufficiently shown " by the frequent return of fever from the repulsion of morbific matter by external remedies." The theorv here propounded may be questionable as resting on hypothesis, but the facts with which it is connected are not the less valuable. It appears, then, that acute rheumatism pre- sents a state of active fever accompanied with local inflammation of one or more joints. And here one of the most important questions respecting rheumatism arises—whether the local inflamma- tion be the cause of the fever, or only its attend- ant ? On the solution of this, much both of the pathology and treatment of rheumatism must de- pend, and accordingly its elucidation will form a prominent part of the present article. In the foregoing description of Sydenham, it appears that the state of febrile excitement pre- cedes the local inflammation. In theoretic specu- lations this fact seems generally recognised, yet it does not appear to have been kept steadily in view either by speculative or practical writers. The term symptomatic fever, so often applied to the constitutional disturbance, implies that this was regarded rather as a contingent result of the local inflammation, than as a precursor or cause of it. To determine this point is of much importance, for by the decision must the whole course of treat- ment be influenced. If the local inflammation, whether seated in the muscular, though more fre- quently in the fibrous tissue of the affected parts, be the cause of fever, as implied by the terra symptomatic, the reduction of local inflammation by the most direct means would be the best and most effectual relief; and this being duly attended to, the contingent fever might, according to the familiar axiom, sublata causa tollitur effectus, be little regarded. On the contrary, if the state of fever, or rather that condition of the habit which gives rise to fever, be the real source of rheumatic seizure, then should the constitutional state be chiefly attended to, and local treatment be only subsidiary to that by which the derangements of the constitution are rectified. Wc hope cleaily to show that the constitutional state is that which chiefly claims our regard in the treatment of rheu- matism. When acute rheumatism occurs in its most active state, so intense is the inflammatory fever attendant, that whatever theory of the disease be entertained, the fever claims its full portion of at- tention, and is met by adequate activity of treat- ment. Bleeding, purging, and other means of reducing fever are promptly and freely employed, the more so as experience has shown this treat- ment to be indispensable for abating the local in- flammation. This being the case, then, it may be asked, of what importance is it to decide whether the local or constitutional affection is to be re- garded as the primary disturbance, inasmuch as the same treatment relieves both < It would be sufficient to answer that truth ought always to be ascertamed, for it can never be unimportant. Were acute rheumafsm in its more active state to be alone co derej( the importance of ^ ^.^ SJLn 7 b°Vhe l0cal and constitution.. of corresn6 d,emandlng the viS°rous employment ;::S;s mer- ^ »*** thpeyminor aegrees ot the same disease, constituting what is gatTd itCw7 ° ^^T' C°me t0 b* ^Iti- fnvSes the:e T",that the'r ?SenUal ch^tet involves the point at issue; and that unless this be determined as truth and reason £££ t RHEUMATISM. practice in a malady which is more prevalent, causes more suffering, and leads to more decrepi- tude than almost any other, must be vacillating, imperfect, and unsuccessful. It will materially abridge the present article to refer to certain general principles of pathology al- ready detailed in the articles Gout and Pletho- ra. These principles apply directly to rheuma- tism, and through them alone can its pathology be adequately unfolded, or its treatment rationally explained. Acute rheumatism principally attacks the young and vigorous. The period of life most subject is said to be from puberty to thirty-five years. Though no age is exempt, it yet more rarely oc- curs in the very young, or in advanced life. This circumstance alone would seem to indicate some connection between rheumatism and fulness of habit, or that approximation to plethora which was formerly noticed as exuberance of health ; and if rheumatic seizures be duly scrutinized, they will be found to take place in those who from plethora, whether absolute or relative, are prone to fever or inflammation on any exciting cause being applied. The extraordinary health so often remarked by patients as having immediately preceded the rheu- matic attack is sufficiently intelligible. But direct evidence of the state of constitution in which at- tacks of rheumatism occur is amply shown in those who, having had the disease, are liable to its recurrence, and on this account compelled to watch the premonitory indications of an attack. In these, constitutional disturbance of a febrile kind, marked by all the phenomena formerly de- tailed as denoting the transition of plethora into febrile excitement, will be invariably found to exist for a sensible time before the disease presents its full character by the establishment of a local inflammation. And to these premonitory indica- tions should the earliest attention be given, for it is in this stage that relief can be most speedily and effectually afforded. By reducing plethora and subduing febrile action in this stage, the local inflammation may be wholly averted, and thus may be prevented not only the injury which the joints, when affected, are liable to sustain, but also the susceptibility to impression from slight causes which reiterated attacks of rheumatic in- flammation never fail to leave. The local inflammation of acute rheumatism undergoes a change during its progress which seems to have escaped observation. It exhibits at different stages two conditions, which may be conveniently distinguished as primary and second- ary. The former is the immediate result of the rheumatic seizure, and must be attributed to the specific cause, whatever it may be, from which the disease derives its distinctive character. It differs from common inflammation in being more tran- sient, for it is capable of rapid subsidence without any trace of its attack remaining. When this inflammation migrates from joint to joint, the oc- currence of a fresh inflammation is oftentimes followed by a quick subsidence of that which im- mediately preceded. Still more signally does this rapid subsidence take place if active treatment for the relief of the constitutional inflammation be resorted to immediately on the attack occurring, Vol. IV. —4 c and before the secondary inflammation has hud time to supervene. In this respect the primary or specific inflammation of rheumatism has a close analogy with that of gout, from which it differs, however, in having a stronger tendency to pass into inflammation of a more ordinary and perma- nent kind. This specific inflammation is promptly relievable by constitutional treatment, no local ap- plications being at all needed. When from the severity of the attacks, or from neglect or delay in having recourse to suitable discipline, the specific inflammation lingers in a joint, a secondary inflammation results, more per- manent in its nature, which does not immediately subside on the constitutional inflammation being subdued, and which generally leaves some traces of its existence, in effusion into the cellular mem- brane or bursas mucosse, or in more or less thick- ening and rigidity of the ligaments and other membranes surrounding the joints. The distinc- tion here noticed is important, because it has a sensible influence on the local treatment of rheu- matism, both acute and chronic. Causes of acute Rheumatism*—The chief, if not the only exciting cause, is the application of cold to the body when unusually heated. Cold is more liable to produce this effect when com- bined with moisture, whence a cold and humid atmosphere, and wet or damp clothes, are the most frequent sources to which rheumatism can be traced. Partial cold, as when parts of the body are subjected to currents of cold air, is very apt to give rise to rheumatism. When the body is pre- disposed, a very transitory exposure of this kind will suffice to bring on an attack; if the current be sustained for any time, few will wholly escape some contingent suffering. Of the fact that rheu- matism is so excited there can be no doubt. When it is reflected, however, that for every instance ol rheumatism so induced, numbers continually en- dure a much or greater exposure to the alleged cause without any disease ensuing, too much im- portance should not be attached to it. [Other causes have been enumerated, such as the repercussion of eruptions, the stoppage of an accustomed flux, &c. These may exert an influ- ence, if a predisposition exist; but such influence is not easily appreciable. Recently, it has been affirmed by Messrs. Maddock arid Sigmond, that where there is a disposition to acute rheumatism, the use of copaiba may develop it.] Of far greater moment is it to regard the predis- position, without the concurrence of which either no rheumatism will take place, or it will be slight and partial, exhibiting none of the constitutional disturbance and febrile excitement which charac- terize acute rheumatism. A predisposition is said to be given by many circumstances, as age, tem- perament, climate, season of the year. Even he- reditary liability has been classed among the pre- disposing causes, and possibly with reason, [and n is affirmed by Dr. R. B. Todd, (Practical Remark* on Gout, Rheumatic Fever, &c. Lond. 1843,) that the children of gouty parents are more liable to the disease than those who have not labourer under the gouty diathesis.] Each of these merits attention, but the circumstance common to all 01' them, and that which has most influence in nr 2G RHEUMATISM. ducing the disease, is a state of general constitu- tion, which from the prevalence of plethora, either absolute or relative, is prone to be aroused by any excitement into febrile or inflammatory action. This subject having been fully discussed in its proper place, (sec Plethora,) it will suffice on the present occasion to apply to the consideration of rheumatism the doctrines already explained. It furnishes a presumption, at least, of these doc- trines having some foundation in truth, that cor- responding principles have been advocated by one of the most enlightened pathologists of the present day. M. Andral, in various parts of his luminous Treatise on Pathological Anatomy, traces a variety of structural lesions, as well as the inflammatory actions which induce them, to a redundancy of nutritive matter in the blood, supporting his views with a copiousness of illustration, matured expe- rience, clear discernment, and sound judgment, which claim the respect Jnd confidence of every intelligent mind. These views, too, are so reiter- ated throughout the work as to show that they were not a mere transient conception, but a deli- berate conviction deeply impressed. A few extracts will evince that in these asser- tions we do not misrepresent this acute and philo- sophic writer. In discussing the effects of hyper- emia, or excess of blood, on particular tissues, he says: — "The hyperemia, instead of being con- fined to a simple organ, may exist at the same time in every organ of the body. The general capillary system is thus overloaded with blood, and the whole system is said to be in a state of plethora or polyaemia. I shall not enter into a de- tail of the circumstances which characterize this state, the essential character of which seems to consist in the formation of a greater quantity of blood than is necessary for the purposes of nutri- tion and secretion. There are some individuals who, according to common observation, naturally make a greater quantity of blood than others. In general, those persons who live high, and make but little exertion, mental or corporeal, are most liable to this affection. It has been said, but with- out the slightest proof being adduced in support of the assertion, that an appearance of plethora has been produced in some individuals by an in- ordinate expansibility of the blood. When the blood-vessels contain a greater proportion of the nutritive fluid than is necessary to supply the de- mands of the different organs, the superabundant quantity becomes a permanent source of excitation to the solids, and at the same time the blood has a remarkable tendency to accumulate in different organs; so that, in such case, the whole system is in a general state of excitation, and some of the organs may become the seats of local congestions of various degrees of duration and intensity. In- deed, the phenomena which result from the ple- (honc diathesis, cannot properly be termed morbid unless when some local congestion is formed. Sometimes the brain is the seat of the congestion, and then follow the various symptoms of the cere- bral disease, giddiness, headach, drowsiness, alter- ation af the sensorial and intellectual faculties, &c. which may be so violent as to induce death, and yet leave no trace of disease except a little more blood than usual in the cerebral vessels. Sometimes the congestion more particularly affects the pulmonary organs. The dyspnoea ^h a companies this form of the disease •«-» JT ™ unusual quantity of blood transmitted through^the lung* which necessarily requires a cornjpondmg quantity of air to fit it for the purposes of the ^circulation. It « this want of proportion between the blood which requires to be aerated, and the quantity of air inspired for that purpose, which produces the dyspnoea. In other cases the complication of palpitation with various degrees of dyspnoea proves that the heart has become the seat of congestion.' Corresponding effects are traced through other organs and tissues, and due notice is taken of the constitutional derangements resulting from polyae- mia when no organ more especially suffers, as well as of the prostration of strength or false ady- namia, as it is expressively called, which so gene- rally attends this state. The section closes with remarks which are too apposite to our present purpose to be omitted, however reluctant we may be to indulge in lengthened quotations:—"The morbid state which I have now described, and to which may be referred some of the species of con- tinued fever described by the older nosologists, may terminate in recovery or death. When the termina- tion is favourable, the symptoms gradually improve as the superabundant quantity of blood, the original source of all the accidents, is diminished by absti- nence and bloodletting. When death ensues, the post-mortem examination generally exhibits traces of well-marked inflammation of one or more organs. This inflammation seems to have taken place subsequently to the commencement of the febrile paroxysm ; at least the symptoms would lead us to this conclusion. But on other occasions no trace of inflammation can be discovered, and the only morbid appearance consists in a simple accumulation of blood in the capillaries of the dif- ferent organs, their textures remaining perfectly unaltered. These slight congestions affecting si- multaneously several organs, may, by the various morbid sympathies which they excite, produce as violent and formidable symptoms as the most seri- ous organic lesion of any individual organ. In such case, where are we to assign the origin of the disease ?—Wherever the blood is distributed, there derangement of function is found. In the blood, then, indisputably resides the first cause of the disease; the lesion of the solids is only a se- condary affection, but may, notwithstanding, be- come, during the progress of the disease, the pro- minent affection, and give rise to many and for- midable accidents. In noticing fevers, he particularises one class which he refers specially to excess of fibrine in the blood. "Lastly, the third class of fevers appears to be more particularly connected with alterations of the blood. On this head I can but refer to what I have already said, when treating of the diseases that may arise from that source. I shall content myself at present with repeating that the fever termed inflammatory seems to me often to arise from no other source than the blood bemg too rich in fibrine." Again, in considering the lesions of the blood, he refers the occurrence of inflammatory fever, not only to a "eneral hyperemia or excess in quantity of the circulating iluid, but more particularly to an altered condition RHEUMATISM. 27 of its quality arising from redundancy of fibrine. " I have already established the fact that, under the influence of a state of general hyperemia, every organ becomes excited ; that death may result from such excitation ; and that a super- abundance of blood is found all over the body, but in no part is there any serious lesion, any alteration of texture. In" such cases there exists that state of pyrexia, termed by nosologists in- flammatory fever. But if, instead of being simply in excess, the blood contains more fibrine than ordinary, its exciting power will be still greater, and what it did in the former case merely by its increased quantity, it will now do by its alteration of quality." In fine, he applies the doctrines thus propounded to the particular disease which is the subject of the present essay. " Now if we mark the symptoms and progress of acute rheumatism, we find that very often a well-marked febrile action with a strong reaction, but without any symptom whatever of local affection, precedes the pain. In a word, there is first an inflammatory fever, and then rheumatism. Next observe the extreme mobility of the rheumatic pains. They run along in a manner wherever the blood is dis- tributed ; the application of leeches often removes the pain from one part, but it soon shifts to an- other, and not unfrequently it quits the articu- lating tissues and fixes on different internal organs, producing, by the derangement of their functions, symptoms more or less severe. It often happens that bleeding from a large orifice puts an end to the disease, as if by diminishing the mass of blood it proportionally diminished the stimulus that promoted all these shifting irritations." The doctrines here advanced we believe to be founded in truth, and capable of furnishing much valuable guidance in the investigation and treat- ment of disease. In such copious extracts we may appear to have made too free with the pages of an author whose works are so generally known, but we could not resist the temptation of fortify- ing, by the authority of so distinguished a patho- logist, principles which we have long maintained, and which we have endeavoured already to illus- trate in the articles Gout and Plethora. They will suffice, we trust, to justify the assertion lately made, that whatever importance may .attach to the exciting cause of acute rheumatism, the pre- disposition induced by a plethoric state of consti- tution is far more entitled to the practitioner's attention. [As stated, however, in the article Plethora, M. Andral has pointed out the marked difference ^tween the condition of the blood in it and in in- Sainmation, and has shown that the increase of fibrin in it obeys the same laws as in the ordinary phlegmasia. He analyzed the blood of forty-three bleedings : in one of which the fibrin marked four, —the healthy proportion being three in 1000 ; in six, it marked five ; in fifteen, six ; in thirteen, .seven ; in three, eight; in three, nine ; and in two, ten. When, however, the rheumatism was sub-acute, it oscillated between four and five; and when decidedly chronic, it did not exceed the healthy proportion. A recent writer, Dr. R. B. Todd, (op. cit.) regards both acute rheumatism and gout to be diseases of the blood, the pheno- mena of which are due to the presence of a mor- bid element in it, generated under the influence of particular causes, " by an abnormal chemical action of the blood itself." It does not often happen that opportunities oc- cur for examining the textures around the joints, whilst the rheumatic affection is active in them. As the disease rarely proves fatal, except by the supervention of inflammation in some of the fibrous or muscular tissues, seated internally, the mischief there is generally so predominant, that, for some time before death, the joints cease to be the source of suffering. Under these circum- stances, it is not surprising that pathologists should differ as to the precise seat of acute rheu- matism of the joints. It has been already re- marked, that it invades every muscular and fibrous tissue, and that alternately the serous membranes may be implicated. Such may be the case in the articulations,—the synovial, which is a serous mem- brane, becoming affected last. On dissection, no decisive appearances may be met with. At times, the veins around the joints have been found gorged with blood ; the ligaments, periosteum, and syno- vial membrane being injected, and thickened, with small collections of matter in the surrounding cel- lular tissue, and accumulations of pus or serum in the cavity of the synovial membrane. (Ferrus, art. Rhumatisme, in Diet, de Med. 2de. edit, xxvii. 567, Paris, 1843.) It is clear, that the hyperemia of acute rheuma- tism—active as it is—can scarcely occasion any great organic changes, inasmuch as, in the course of a few hours, it shifts its seat, and leaves behind no evidences of its previous existence. This mobility has, indeed, given rise to the opinion, amongst many, that the disease is essentially seated in the nervous system ; that the sanguiferous system is affected secondarily, and that it is very probable the nervous filaments of the diseased parts are more considerably involved than any other tissue. Dr. Mackintosh, (Principles of Pathology, &c. 2d Amer. edit. ii. 461, Philad. 1837,) who sup- ports this view, remarks, however, that he has seen cases, which presented symptoms similar to those of rheumatism, in which, after death, the lymphatics of the limb were found inflamed, and filled with a puriform fluid. Some, again, have considered acute rheumatism to be nothing more than acute inflammation of the lining membrane of the arteries. The whole disease is certainly peculiar, and appears to be more neuropathic than ordinary inflammation. Its extremely changeable character sanctions this idea, and the remedies are not always those which we should think of pre- scribing in ordinary active phlegmasia.] Diagnosis of acute Rheumatism.—This may be briefly disposed of. The only disease with which it is liable to be confounded is gout, in treating of which the distinctive character of each malady has been sufficiently noticed. For- merly discrimination in this respect was deemed of high importance, the prevailing theories of gout demanding a course of treatment very dif- ferent from that to which rheumatism was sub- jected. In the present day a juster pathology of gout assimilates the treatment of both diseases sufficiently to render extreme accuracy of dis- crimination of very slight moment. Prognosis of acute Rheumatism* — T?«? '■H RHEUMATISM. prognosis is so dependent on the promptitude with which suitable treatment is resorted to, that any remarks on the natural course or duration of the disease are of little worth. Generally speak- ing, there is little immediate danger to life, there being no inflammatory disease of equal intensity which so little deranges the vital functions. This, most probably, is owing to the disease expending its violence on the joints and other external parts, and being little prone to attack the viscera. The peculiar character of the inflammatory action too, and the little liability which it has to pass into suppuration, or undergo the other changes conse- quent to phlegmonous inflammation, may account for the safety with which even the metastasis of rheumatism to internal parts is borne. It is cer- tain that such metastasis is not attended with so much danger as the severity of the symptoms would seem to denote. In early life we were often appalled by the metastasis of rheumatism from the joints to the heart, an organ more pecu- liarly liable to this transition than any other. More extended experience abated such fears, by showing that the immediate danger was by no means commensurate with the suffering expe- rienced [Still, the pericarditis and endocarditis of acute rheumatism must be regarded as most dan- gerous complications—if they may be so termed —of the disease ; for even if the patient recovers, which is often the case, from the immediate attack, cardiac lesions are apt to remain, which may lay the foundation for disease afterwards. M. Bouillaud (Traite Clinigue du Rhumatisme articulaire, Paris, 1840,) has affirmed, that about one half of those who suffer under acute articu- lar rheumatism are affected with pericarditis; and we know that endocarditis is a common accom- paniment. One of the most important points, therefore, in the management of acute rheuma- tism is to watch the supervention of the morbid action in the fibro-serous tissues of the heart. It is not necessary to repeat here the symptoms of pericarditis and endocarditis (See Pericardi- tis) ; but the occurrence of dyspnoea, with more or less anxiety, jerking, or feeble and rapid pulse, and tumultuous action of the heart, ought to iirect the attention of the practitioner to that viscus, and if he discover, by the physical signs and functional phenomena, the existence of in- flammatory action there, it must be treated as if (he disease were unconnected with rheumatism ; for nothing is better established, according to M. Andral, (Cours de Pathologie Interne,) than {hat, although primary rheumatism, seated in the Sbrous and muscular tissues around the joints, is remarkable for its great and rapid change of seat; secondary rheumatism—if it may be so termed— loses this mobility when it fixes upon a serous membrane. Dr. Graves (Clinical Lectures, Amer. edit. Philad. 1842,) states, that rheumatic fever may exist without the affection of the joints; and that pericarditis may occur as a primary symptom before the appearance of the articular swelling. This is probable. The writer has certainly seen many cases in which the signs of pericarditis were amongst the earliest phenomena.] If an attack of rheumatism be treated at the onset with due activity and discnm.nat.on,t m 7 be relieved in a very few days w.thou the affcxled ioints sustaining any injury. But both w, h d local ravages, much will joints respec depend on su respect to time ana---- ~ - , itable discipline being resorted to ecific inflam- mation of the joints becomes complicated v penu on suuauiv «---r- - :„fl,.r», d adequately pursued, ere the spec.fic inflam- mation of the joints becomes complicated with that which we have termed secondary. The specific inflammation we have repeatedly seen subside in twenty-four hours, leaving behind but little trace of its accession. When secondary inflammation, however, has been suffered to su- pervene, the case is materially altered, and greatei obstinacy of local affection may be expected. It might be laid down almost as an axiom, that the severity and duration of the disease are propor- tionate to the degree of plethora present, the ac- tivity of inflammation, and the length of time during which the morbid actions are suffered to prevail unrestrained. If the plethora be great, inflammation high, and much delay take place in resorting to efficient means for correcting the con- stitutional derangements, then would it be diffi- cult to assign limits either to the constitutional disturbance or local ravages, both of which may continue, though with abated force, for months or years, to undermine health and cripple the limbs ; in other words, acute rheumatism may then pass into chronic of the most inveterate and intractable kind. Thus, though acute rheuma- tism rarely destroys life by its immediate seizure, however violent, this furnishes no excuse for su- pineness or inactivity in the treatment; for if not radically relieved in its early stage, the disease, even when of no extraordinary violence, may be- come so confirmed as to yield afterwards with difficulty to the most active and judicious use of remedies, while progressive disorganization of joints may entail protracted suffering and lasting decrepitude. It is true that a slight rheumatic seizure may, like a gouty paroxysm, pass away without medical interference, the efforts of the constitution sufficing for relief. But this is not its general character; and to rely on such a contingency would be in the highest degree rash and inexcusable. When- ever an attack of acute rhematism occurs, the constitution must need some relief, which enlight- ened practice will never withhold. To neglect of this principle may be ascribed a very large pro- portion of the decrepitude which the victims of rheumatism so continually present. There is no truth of which we are more thoroughly persuaded, than that if rheumatism were at its onset treated as its real nature demands, and if due care were afterwards taken to guard against its recurrence by prophylactic measures judiciously directed and adequately pursued, there need not from this malady be one case of disorganized and crippled joints for every hundred that are so afflicted. The effects of the earlier treatment will, therefore, in general, dec.de the prognosis. There is infiamma- ory fever to subdue, local inflammation to remove. If early bloodletting in subduing the fever make prompt impress.on on the local auction, so that both pain and swelling quickly subside thus marking the local inflammation as slill reaiZS its specific character unmixed with secondary effects, speedy and effectual relief „»y be «n RHEUMATISM. 29 fiQC/iiL.y predicted, medical treatment judiciously conducted being fully capable of ensuring it. When febrile action is inveterate, and it is often- times very obstinate, though chiefly so when the earlier periods of disease have been neglected or inadequately treated, a tedious progress may be expected, for so long as fever remains unsubdued are the local inflammations incapable of removal, cither keeping their ground unmitigated, or if abated by topical remedies, continually recurring. Again, when abatement of fever is not followed by quick subsidence of local swellings, in conse- quence of the latter having passed into the secon- dary stage, and especially when effusion and organic changes have already taken place in the affected joints, then is the restoration of the joints much more tedious, though great local derange- ments will admit both of speedy and decisive relief, provided the local mischief be not rendered inveterate, or continually renewed by unsubdued fever. Much, too, depends on the state of constitution in which acute rheumatism occurs. In a healthy subject, capable of bearing the depletory and other treatment required for relief, great reliance may be placed on the efficacy and certainty of the curative process. When the constitution is depraved by long-continued relative plethora, with its attendant febrile excitement, and especially if the feebleness, natural or acquired, be such as to render caution necessary in carrying bloodletting and other reme- dial processes to the requisite extent, more pro- tracted disease and more tedious recovery must be he natural and inevitable consequence. It is said that rheumatic inflammation does not tend to suppuration or gangrene, and the remark is generally true. Yet we have seen abscess of the cellular membrane supervene on rheumatic inflammation, and we have also witnessed slough- ing ensue when leeches have been applied to a highly inflamed joint without adequate constitu- tional treatment being conjoined. The most frequent consequences are, gelatinous effusion nto the bursa?, thickening and rigidity of the liga- ments and other membranes surrounding the joints, contractions of the limbs, and wasting of the muscles, all of which will come under considera- tion in the latter part of this essay, where it treats of chronic rheumatism. Treatment of acute Rhc iimatism.—The indications are here to subdue fever and remove inflammation. It has been already shown that the former claims the first consideration. The promptitude with which the local inflammation in its earliest stage yields to the treatment by which a plethoric state of constitution is corrected, and febrile action allayed,—and the obstinacy of the local ailments, whenever the constitutional state is overlooked or inadequately treated, furnish the best proofs of the correctness of this pathology. In its simplest form and early stage, acute rheuma- tism is speedily and effectually relieved by anti- phlogistic treatment, properly directed and ade- quately pursued. Bleeding, purging, salines with antimony, diluents, and abstinence, suffice both for subduing the general fever and removing the local inflammation. It continually happens, however, that these means, however actively or perseveringly employed, will not succeed in re- c* establishing health; a lurking fever remaining unsubdued, the blood retaining its huffy crust even when the crassamentum is reduced far below its natural and healthful proportions, and the local inflammation maintaining its hold of the affected joints. Further means are then required, which will be noticed in their proper place. The treatment of the simple and more manageable form must be first discussed. One of the earliest practical writers on this complaint was Sydenham ; and so direct and ju- dicious was his practice, that we cannot do better than fo make it the text on which to comment in treating this part of the subject. Sydenham's theories of disease often involved the pathological fantasies prevalent in his day ; but it is his signal merit that he never suffered them to mislead him from the path which his clear discernment and practical experience enjoined him to follow. He attributed the local affection to " the derivation of the febrile matter to the limbs," which, as he observes, " the frequent return of the fever from the repulsion of the morbific matter by external remedies sufficiently shows." But we cannot perceive that he was influenced by this hypotheti- cal principle, further than to adduce it in explana- tion of facts which his experience had taught him. He had witnessed the inefficacy of local treat- ment, and also the increase of constitutional dis- turbance which resulted when this alone was trusted to, and he wisely abstained from repellent applications. Having described the disease with some of its modifications, he gives the following concise instructions for its cure. " Since both kinds of this disease seem to arise from inflamma- tion, as appears from the concomitants just men- tioned, and especially by the colour of the blood taken away, which exactly resembles that of per- sons in pleurisy, which is universally allowed to be an inflammatory disease, so I judge that the cure ought to be attempted only by bleeding, the heat of the blood being in the mean time abated by cooling and thickening remedies along with a proper regimen. Accordingly, as soon as I am called I order ten ounces of blood to be immedi- ately taken away from the arm of the side affected, and prescribe a cooling and incrassating julep. To ease the pain I order a cataplasm prepared of the crumb of white bread and milk tinged with saffron, or a cabbage-leaf to be applied to the part affected, and frequently renewed. With respect to diet I enjoin a total abstinence from flesh, and even from the thinnest flesh broths, substituting in the place barley-broth, water-gruel, panada, and the like. I allow only small-beer for drink, or, what is more proper, a ptisan prepared of pearl- barley, liquorice, sorrel-roots, &c. boiled in a suf- ficient quantity of water, and I allow the patient to sit up some hours every day, because the heat which arises from lying always in bed promotes and increases the disease. The next day I repeat the bleeding to the same quantity, and in a day or two after, as the strength will allow, I bleed again. Then interposing three or four days, as the strength, age, constitution of the patient, and other circumstances indicate, I bleed a fourth time, which is generally the last, unless too hot a regimen has preceded, or heating remedies have been exhibited without necessitv. But the us- 30 of opiates requires more copious bleeding; and, therefore, though the pain be ever so violent during the whole course of the disease, yet when I intend to effect the cure solely by bleeding, I judge it highly necessary to refrain from opiates, because the disease is fixed thereby, and does not yield so readily to bleeding; so when such medi- cines are given too frequently, bleeding must in consequence be oftener repeated than is otherwise necessary. Besides, in the height of the disease, they do not answer the expectations we have con- ceived of them. Whilst the above-mentioned remedies and regimen are carefully continued, I inject glysters made of milk and sugar, between times on the intermediate days of bleeding, earnestly recommending the exact observance of these directions for at least eight days after the last bleeding; and then I prescribe a gentle purging potion to be taken in the morning, and in the evening a large dose of the syrup of white poppies in cowslip flower-water, whereby a check is put to the tumultuary motion of the blood which might otherwise occasion a relapse. This being done, I allow the patient to return by de- grees to his customary way of living in relation to diet, exercise, and air ; but, at the same time, caution him to refrain for a considerable time from wine and all spirituous liquors, salt or high- seasoned flesh, and, in general, from all food of difficult digestion. After having repeated bleed- ing as above specified, the pain greatly abates, though it does not go quite off; but as soon as the strength returns, which bleeding had greatly impaired, the symptoms will vanish, and the patient perfectly recover." In the simplicity, fitness, and activity of the foregoing course of treatment, there is much to admire. It comprises the more essential articles of antiphlogistic discipline, bleeding and absti- nence ; it discourages the premature use of nar- cotics, which, when employed too early, or in substitution of depletory measures, only mask the symptoms even when they allay pain, while they too often exasperate the disease, rendering it both more violent and more obstinate. It also incul- cates a salutary reserve in the return to animal food and fermented liquors. That under this simple treatment many would pass safely through the disease, there can be no doubt, although re- covery would certainly be slower than it might be rendered. But cases continually occur in which this treatment would be utterly inadequate, the febrile action maintaining its ground, and the local inflammation migrating from joint to joint, notwithstanding the diligent employment of all the means which Sydenham's practice in the dis- ease comprises. In this practice one great defi- lency is observable, the use of purgatives in aid of bloodletting not being at all enjoined. For regulation of the bowels, clysters of milk and sugar are trusted to, and not until eight days after the last bleeding is a gentle purging potion pre- scribed. In this and other respects, later expe- rience has added much to our means of combating acute rheumatism. When this disease occurs in its most active state, the means suited for reducing plethora, abating fever, and checking the progress of in- ll.tmination, must be promptly and adequately RHEUMATISM. Employed; full bloodletting and active purging, ired to lower the circulation a arrest with the united powers of eoIch.com andam.mo- nv being required to lower the circulation and Y' the evils which inflammatory action when " . . ___„;~„ 'Pho first nro- arresi mc c»i^ .....— - fi . unrestrained is sure to occasion. The first pro- cedure in respect both of time and importance is bloodletting. In many instances the use of th.s directed by Sydenham would suffice, but in many it would fail. As a rule of practice, therefore, Sydenham's directions in this respect are defective, as not embracing conditions of disease wh.ch are of frequent occurrence, and for which the deple- tion directed by him would prove utterly made- quale. Indeed, no express rule in this respect could be laid down, both the amount and fre- quency of venesection being in every instance dependent on the degree of plethora existing, the activity of fever and inflammation present, and the natural powers of the constitution to be acted on. The pathology of inflammation, and the use of bloodletting most effectual for subduing it, have been so amply discussed in the articles Gout and Plethora, that to recapitulate what has been already advanced on these points must be need- less. We shall proceed, therefore, on the pre- sumption of the principles inculcated in those articles being clearly comprehended, and in con- formity with these principles state practically how the lancet can be most successfully used. In or- dinary cases the loss of twelve, sixteen, or twenty ounces of blood may suffice to check disease and prepare the way for the subsidiary treatment. But if absolute plethora be considerable, inflam- matory action high, and the constitution robust, blood must be drawn to much greater extent if adequate impression is to be made on disease. In such case the rule should be not to abstract any assigned quantity, but to carry the bloodletting to the extent of making a sensible impression on the force of circulation. Thirty or forty ounces of blood may require to flow ere this is effected, and so essential is the impression alluded to, that even large bleedings, if not carried to this extent, will fail to produce their full effect in restraining in- flammatory action. It continually happens in cases of active inflammation, that notwithstanding the loss of thirty or forty ounces of blood, the pulse does not yield, but maintains its hardness, while the abstraction of a few ounces more, by inducing a disposition to syncope, completely checks the inflammatory action and abates the violence of the disease. By making the consti- tutional powers the measure of the depletion, less bleeding on the whole is needed; thus by this mode blood is virtually saved and unnecessary exhaustion prevented, a single venesection carried to the necessary extent being far more effectual than reiterated bleedings to a far greater aggregate amount, if these be respectively of insufficient extent. Bleeding to actual syncope is not desira- ble, but if inflammation be high, some impression on the pulse should be manifested. If this begin to falter, while nausea is felt, the lips grow pale, and perspiration be«in to bedew the forehead such bloodletting may be relied on for accomplishing all that this remedy is capable of effecting. This use of the lancet, however, can only be required where severity of symptoms with vigorous habit demands such active treatment. In a lai■« r,™ RHEUM ATISM. portion of cases much more moderate depletion will suffice. From twelve to twenty-four ounces of blood may be regarded as the ordinary limits, and many repetitions are never advisable; for when bloodletting to such extent, assisted by purging and other febrifuge treatment, does not make sensible impression on disease, other more adequate means of arresting its progress must be resorted to. Blood maybe drained away until the body is blanched and the crassamentum reduced to a tithe of its just proportions, yet febrile action will continue, inflammation be unsubdued, and the blood drawn be still buffed and cupped. It is right to mention here, that although a full and hard pulse is generally attendant on acute rheumatism, yet the absence of hardness is no evidence of active inflammation not being present, or of bloodletting not being needed. If the gene- ral symptoms concur to indicate inflammatory action, then, though the pulse be soft and com- pressible, bloodletting is nevertheless essential, the blood drawn in such case being almost uniformly buffed and cupped, the pulse rising after venesec- tions, and disease more rapidly subsiding. [Of late years, the profession have been startled by the extent to which bloodletting has been re- commended by M. Bouillaud (Op. cit.) ; bleeding coup sur coup, with the view of " strangling" the disease, to use his own expression. The writer has had recourse to it in what appeared favourable cases; but the results have not been equally happy ; and it has seemed to him, that the too vigorous use of the lancet has occasionally rather favoured the shifting of seat, which has been so much dreaded. It can, of course, only be admis- sible in vigorous individuals, and even in them, a more sparing use of the lancet, with the agents to be mentioned presently, appears to be less liable to objection. There are cases in private practice, and most of those that are seen in our eleemosy- nary institutions, in which any abstraction of blood from the general system could not fail to prove injurious. As an adjunct to general bloodletting, the tar- trate of antimony and potassa has been highly extolled of late years, and there are cases in which its sedative influence has been highly advantageous. The writer has frequently prescribed it under the restrictions and inculcations mentioned under another head (See Pneumo.via), and occasion- ally with the best effects. It has seemed to him, however, that the antimony has acted most bene- ficially when it produced nausea, and the nausea was kept up two or three days in succession.] The next measure is to purge freely the stomach and bowels ; and here again we must refer to what was formerly advanced on this subject in illustration of the necessity of suitable and ade- quate purging being employed in aid of blood- letting. As soon as may be after bloodletting, a full dose of calomel combined with antimony (either James's powder or tartarized antimony) •should be given, and in a few hours after a cathartic draught. The bowels being well evacu- ated, diaphoretic salines with antimony and col- chicum contribute much to allay fever, quieting the pulse, and promoting the several excretions. One of the best forms of saline for this purpose is a combination of acetate of ammonia, camphor mixture, antimonial wine, and wine of the col- chicum seeds, as in the following formula: R. Liquor, amnion, acet. Mist, camphors?, ii f.^ss. Vin. sem. colch. Vin. ant. tart, aa m. xx. Syrup, aurant. f.ji. m. fiat haustus quartis vel sextis horis sumendus. The properties of colchicum and the best modes of administering it have already been so fully dis- cussed in the article Gout, that to avoid needless repetition, we shall refer to what is there stated. It is only necessary to remark that the effect of colchicum on the bowels requires to be watched, for when it irritates them so as to excite active purging, its use must be discontinued. In our early trials of colchicum in gout and rheumatism, we were accustomed to give it in full doses, but, for reasons already explained, we have for many years discontinued them, the salutary effect of the remedy being fully attainable from the more moderate exhibition of it which has just been prescribed. When the use of it irritates the bowels, producing frequent watery stools, discon- tinuing the colchicum suffices in general for the relief of this disturbance ; but should it continue troublesome, moderate doses of Dover's powder are sure to allay it. It has been surmised that the use of colchicum has through irritation of bowels led to ulceration of their mucous membrane, but this effect we altogether distrust. It must be a very rash use of the remedy which could produce any. such effect, and where it has appeared to re- sult, our persuasion is, that the membrane was in an advanced stage of subacute inflammation ere the colchicum was exhibited. We have given colchicum freely and extensively for many years, with caution certainly, though not greater than is required in the administration of every active drug, yet a single instance has never occurred to us in which we could trace any injury to its use, while its medicinal properties have rendered val- uable aid, not only in gout and rheumatism, but in many other inflammatory diseases. [Aconitia, delphinia, and veratria, have been used both internally and externally ; and cimici- fuga carried to the extent of producing catharsis, and even slight narcosis, has likewise been of service. Of the different revellents, cupping on the back, strongly recommended by Dr. J. K. Mitchell, has appeared to be most frequently attended with happy results. An idea has been entertained that this has been owing to the depletion and revulsion effected near the origin of the nerves that are con- cerned in the articular inflammation. Whatsoever view may be entertained as to this matter, it is unquestionable that the highly sensitive integu- ment of the back is an excellent locality for revul- sion in many diseases; and it is not necessary that the mischief should be directly or indirectly connected with the spinal marrow, or its sheath, to explain this. The writer has seen the intense suffering in the joints as effectively relieved by cupping over the loins as by any other agency.] As the extent and repetition of bloodletting must depend on the activity of disease and vigou' of constitution, so must the use of purgatives b« regulated by the condition of the bowels, and th« necessity for purging which the stools may evince 32 So long as these are dark, slimy, fetid, and other- wise unhealthy, must purgatives be used ; and the most effectual are those by which the morbid se- cretions of the alimentary canal are evacuated. Pills of colocynth, calomel, and tartarized antimony should be given at intervals, and, if necessary, cathartic draughts should be interposed. When fever declines, and the stools present a more healthy appearance, milder aperients will suffice. Under such treatment low diet and a cooling regimen are indispensable. Barley-water or toast-water is quite sufficient during the inflammatory stage. Animal food and fermented liquors of every kind are prejudicial, and should be carefully withheld. The several means now pointed out will in many instances suffice to allay fevers, remove in- flammation, and restore health. But cases occur in which neither fever nor inflammation can be thus subdued. If active treatment be not resorted to on the first accession of disease, or if it be not urged to the requisite extent, inflammatory action acquires an inveteracy which simple antiphlogistic treatment is quite unable to correct. In such cir- cumstances bloodletting may be pursued until the patient become nearly exanguious, yet the blood will still be buffed and cupped, febrile action will remain unsubdued, and local inflammation con- tinue to disorganize and cripple the joints. Even in milder cases of this kind, although per- manent injury may be averted, and perfect reco- very ultimately ensue, yet the successive migra- tions of local inflammations prove harassing to both patient and practitioner. We have seen such inflammation traverse almost every joint of the body, attacking several a second and a third time before the disease yielded. When the pro- gress is favourable, each successive inflammation becomes slighter, until towards the close a mere blush of redness marks the morbid effort. But this course of proceeding is at best tedious and unsatisfactory, even where an issue so favour- able as has just been mentioned is attained. Such result, however, is not to be relied on ; for in the form of disease now considered, it will more fre- quently happen that unsubdued fever will exhaust the general powers, and inflammation inflict its ravages on the joints, producing effusion, thicken- ing of ligaments, with enlargement, rigidity, or contraction. When, therefore, one or two full bloodlettings, assisted by purging, abstinence, and other means, fail to make adequate impression on the disease, it becomes necessary to call in other aids in order to prevent the exhaustion and other ills which repeated bloodletting would occasion. And fortunately one exists which is worthy of our fullest confidence. This is mercury, which, when judiciously administered and made subsidiary to bleeding and purging, is capable of subduing rheumatic inflammation with as much certainty as attaches to the operation of any remedy in any disease. The practice of arresting the progress of rheumatism by mercury has been before the public sufficiently to have made it more generally known and more justly appreciated than it appears to have been. It originated with Dr. Robert Ha- milton of Lynn Regis, who published, in the Me- dical Commentaries of the year 1783, an interest- ing account of the success with which he had administered calomel and opium in the treatment RHEUMATISM. of several inflammatory diseases. So far back as the yc.r 1764 he had been induced to employ calomel for the cure of hepatitis. Its efficacy in the disease and in several other inflammatory affec- tions led him to extend his views of its applica- bility, and to conceive that it was a suitable remedy for inflammation in whatever v.scus or tis- sue this might be situated. He accordingly em- ployed its aid with the best effects in inflamma- tions of every part, and particularly in acute rheu- matism. His practice in the latter was to take blood in proportion to the violence of the inflam- matory symptoms and to the age and constitution of the patient; after which he exhibited calomel and opium at suitable intervals until the disease yielded, or until the influence of the remedy on the constitution was evinced by increased secre- tions from the salivary glands, bowels, or skin. If in twenty-four hours after the use of mercury was commenced, relief did not ensue, or if inflamma- tory symptoms continued unabated, he bled again, and gave the calomel more frequently. Salines, antimony, camphor, and other auxiliaries were combined with bleeding and mercury, and through their united agency he found disease subside with a promptitude which no other mode of treatment could command. When this treatment was em- ployed early in the disease, recovery was soon ac- complished ; if postponed to a later period, its effects were more tedious and uncertain. His ex- perience also taught him that the curative process was most favourable when the salivary glands be- came affected by the medicine. This brief account of Dr. Hamilton's rational and effective practice in rheumatism embraces so many essential points of the treatment of this disease, that we shall have little to add save the detailed instructions which the young practitioner may need for conducting that treatment with discrimination and effect. In confirmation of the truth and accuracy of Dr. Hamilton's views, we may here remark, that hav- ing for hve-and-twenty years pursued the practice and applied the principles which he inculcates, our faith in them has never wavered, and that with ample opportunities for subjecting them to the test of experience, we can truly say that we know of no fact in medicine better established than the power which mercury possesses of subduing inflammations, when used as subsidiary to bleeding and purging. Every case of acute rheumatism does not re- quire mercury for its cure. Bleeding, purging, abstinence, and salines, with antimony and colchi- cum, will frequently suffice. But if, after twenty- four hours, the early discipline has not produced sensible effect on the disease; if after this period fever continues unabated, inflammation unallayed, and further bloodletting be required ; as obstinacy of disease is here sufficiently announced, it is ex pedient to lose no more time, but to resort to the only means by which an adequate check can be given to the malady. Profuse use of mercury is not needed ; both the amount of dose and frequency of exhibition must be determined by the circumstances of the particu- lar case. Although it is desirable to obtain evi- dence of the constitution being affected by the remedy, so far as tenderness of gums indicates it is not expedient to produce this effect very speedi'ly RHEUMATISM. 33 and there are many reasons for enjoining caution in the administration of this medicine. It is not necessary to urge on its full operation, for the curative effect commences ere the specific action on the salivary glands appears. Unless the ple- thoric state of constitution, too, be adequately re- lieved by depletion, there is considerable risk of pressing the use of mercury. On this subject we must once more refer to what has been already advanced respecting it in the article Plethora. The susceptibility of impression from mercury, too, varies greatly in different persons, so much so, that while some cannot be salivated by any quantity, a few grains of calomel will in others induce severe ptyalism, with inordinate swelling of the jaws and extensive sloughing. On every account, then, it is advisable to incline to the mi- nimum quantity capable of acting on the disease. The expediency of combining opium with calo- mel, when exhibited for this purpose, admits not of question. When thus conjoined, it allays pain, abates irritability, prevents the calomel passing off too quickly by the bowels, and promotes its more certain absorption. In general, two grains of calo- mel and a quarter of a grain of opium is a suffi- cient dose, and the frequency of its exhibition will be best guided by the severity and threatened ob- stinacy of the attack to be combated. In severe cases it is beneficial to commence with five grains of calomel, one of opium, and one of tartarised antimony at bedtime, and to pursue the course the next day with the smaller dose. In mild cases it may suffice to give this night and morning; to administer it thrice a day is no inactive practice, and by this use the gums will in general soon become affected. Given every six hours, so ihat, in the four-and-twenty, four doses are taken, is perhaps the frequency that will most commonly be needed. We have never had occasion to en- large the dose, nor to exhibit it oftener than every four hours; but to this extent we have been occa- sionally compelled to employ it. The cases, how- ever, requiring the active use of it are rare. The circumstances to guide its use are the curative effects on the constitutional and local symptoms, and its specific effects on the salivary glands, bowels, and skin : if any of these be signally in- duced, the use of it should abate, and the intervals of its exhibition be lengthened. Unless active salivation take place suddenly, and unexpect- edly, it is never expedient to withdraw it wholly so long as fever lurks or inflammation keeps its ground. The best practice is to lengthen the in- terval, and to do this progressively by reducing the employment from four times a day to three, then to twice, and finally to continue a single dose daily for a short time. By this cautious proceeding, if bloodletting be adequately practised, the bowels freely purged, and no error in diet committed, the beneficial effects of mercury may be ensured with- out any risk of injury and scarcely of inconve- nience. Should salivation chance to advance beyond what would be wished, the evil is but a slight counterbalance to the benefit which mercury confers in the case of this most painful and disor- ganizing malady. When the mouth becomes pain- fully affected, we may here remark that saline purges abate the distress, and that gargles of chlo- ride of soda or of nitrate of silver have considera- Vol. IV. —S ble power in allaying the morbid sensibility of the gums and tongue which is sometimes experienced There are constitutions on which mercury acts so unfavourably, producing great derangement of the nervous system, that its use cann.it be borne. When such sinister effects occur, its use must of course be abandoned ; but such instances are not common, and when they do occur, we strongly suspect that neglect of early depletion is more in fault than any idiosyncrasy inimical to the remedy. While mercury is exhibited in the way directed, the salines formerly prescribed should be continued, and occasional purges should be interposed. The use of the latter should be regulated by the degree of fever and the state of the stools. If fever con- tinues high, with a dry tongue and costive bowels, or if the stools be very dark and slimy, purgatives must be the more freely used. When the bowels are unusually torpid, it is often expedient to sub- stitute for the diaphoretic saline a solution of sul- phate of magnesia in rose infusion, giving this at such intervals as shall keep the bowels free. It is generally conceived that purgatives impede the constitutional operation of mercury, and in conse- quence, when this operation is the object in view, purgatives are usually withheld. Without dis- cussing this point, we shall merely observe that if the degree of fever or the foulness of bowels de- mands purging, it should be carried to the full ex- tent required, without regard to its supposed inter- ference with the effects of mercury. Under such circumstances greater injury would result from the neglect of purging, than even the unimpeded action of mercury would compensate. There are cases in which it is not expedient to combine opium with the calomei, but they are rare. If headach prevail,—if the tongue, instead of becoming moist and clean, grow parched and dark, and the skin be hot and dry,—opium should be withheld, and the calomel given either alone or conjoined with James's powder. [Opium has not unfrequently been given in acute rheumatism, with the view of inducing nar- cosis, and of establishing a new impression and action on the nervous system. Care must, of course, be taken not to push the remedy too far, and yet to keep the patient clearly under its influ- ence. With this view, any of the preparations of opium may be prescribed ; but the soft pill is as efficacious as any other; or the acetate or the sul- phate of morphia or the pulvis ipecacuanha? com- positus ; but the last can be seldom given in quan- tity sufficient for the opium to produce its narco- tic action, without the ipecacuanha disordering the stomach.] The progress of recovery and the experience of a few cases thus treated will readily guide the practitioner in that adaptation of remedies to the exigencies of each case which no specific rules could prescribe. He who possesses himself of the principles on which the treatment here directed is founded, will commit no error in the extent or duration to which he may carry it. There is a period, however, in the progress of rheumatism, even when actively and judiciously treated, which calls for something more than ha? yet been enjoined. In a large proportion of cases. the treatment now prescribed will fully suffice. Ii will subdue fever, remove local inflammation, pr*> 34 RHEUMATISM. vent disorganization of joints, and restore the pa- tient in moderate time to health and the free ex- ercise of limbs. But it occasionally happens that notwithstanding the full employment of all the means directed, a certain degree of fever lingers, the skin continues dry with some morbid heat, the tongue too white, and pains of acute character are still felt in the joints. When this state first met our view, so completely did the assemblage of symp- toms simulate active inflammation, that we hesi- tated whether there was not an actual relapse of disease, and a necessity for reverting to active re- medies. But the indecision was of short duration ; for assured by the treatment already pursued, and the effects produced by it, that inflammation had been successfully combated, we could not regard the supervening state as corresponding in its na- ture to that which we had already corrected, and instead of recurring to bleeding and mercury, we made trial of bark as a preferable agent, and with such benefit, that we have seen it remove, in twenty-four hours, the whole train of symptoms which we have just mentioned. Half a drachm of bark with ten grains of nitre is the combination on which we most rely, giving this twice or thrice a day ; and so effectually does it answer the pur- pose that we are slow to change it. What we have now stated may serve to explain the confi- dence with which some writers have advocated the use of bark as almost a specific in rheumatism. There is undoubtedly a stage of the disease in which it may be beneficially given, but in the acute stage, to which we have hitherto chiefly re- ferred, we at least would not compromise the patient's safety by trusting to bark, while bleed- ing, purging, and mercury were applicable ; and even in what is called chronic rheumatism we would as little rely on it so long as plethora was unrelieved, the pulse high, the bowels loaded, and active fever predominant. When the general state of constitution is restored to the proper ba- lance of its several functions, should some febrile indications linger, and pains continue to infest the joints or muscles, bark furnishes then a valuable and unexceptionable means of correcting the slight remnant of disease, but not before. [The writer has had frequent opportunities for witnessing the exclusive use of both modes of treatment, antiphlogistic and tonic, and it is but proper to say, that he does not recollect to have seen the symptoms in any case aggravated, under the prudent employment of either. In the mass of cases that oc_ur, except in very active, vigor- ous habits,—and it is generally applicable even to them.—a combination of the two modes of treat- ment has appeared as advantageous as any other, —treating the disease during the early period, by the ordinary antiphlogistics, and afterwards en- deavouring io remedy the neuropathic condition by the cautious employment of tonics, as the sul- phate of quinia. Dr. D. Davis, late Profes- sor in the London University, has expressed a confident belief, that cinchona " is the most pow- erful remedy that can be employed even in an in- cipient case of acute rheumatism, and affirms, that he does not remember a case in which the disease was not happily subdued. " I have often recom- mended it," he adds, •' in cases of pure arthritic iheumatism during its acutest stage, and the dis- ease has al lso recom ways yielded to the remedy ; and I have amended it in violent pains of the joints, accompanied by alarming eomphcdtons but never in any one case injuriously to the interest of my patient. I have, therefore, no difficulty ,n recommending its adoption to my medical brethren, and especially to those who are most frequently favoured with opportunities of seeing acute rheu- matism in its earlier stages." Dr. Dav.s prescribes the cinchona in the dose of from a scruple to half a drachm, repeated three or four times daily. He always, however, premises the free abstraction of blood. (See, also, Popham, Dublin Journal of Medical Science, Sept. 1844, p. 50.) M. Briquet, and others, have advised large doses of the sul- phate of quinia—from £i to giss in the course of the 24 hours; and, they affirm, with unusua' success. M. Briquet considers, from his observa tion, that the sulphate is a' powerful sedative, diminishing nervous excitability, retarding the pulse, and lowering the temperature. It has been objected by M. Devergie to this plan, that it is apt to cause serious disturbance in the functions of the brain and organs of sense; but care in regu- lating the dose may prevent this.] The cure of rheumatism by profuse perspira- tion has fallen so much into disuse that it can hardly be necessary to notice it. Yet it was held in high estimation not many years back, and very generally deemed the most effectual mode of treat- ment. The late Dr. Gregory, in his lectures, used to represent sweating as the evacuation most to be relied on for the cure of rheumatism, and to bear his testimony to its efficacy. He gave a caution, however, against resorting to it until the pyrexia had been abated by bloodletting, and stated that his test was, never to employ it until the pulse was reduced to 100. The chief agent was Dover's powder, given in doses of ten grains every two or three hours, assisted by warm cover- ing and copious diluents, the latter to be used only when the perspiration commenced. To be effectual, this required to be kept up for forty-eight hours. This practice has, we believe, been very generally, and, as we think, judiciously, laid aside, the treatment recommended in the foregoing pages being far more certain and effectual, producing less exhaustion, and leaving less susceptibility to recurrence of disease. [Recently, iodide of potassium has been recom- mended both internally and externally, and the treatment by large doses of nitrate of potassa, so highly advised in the last century by Dr. Brockles- by, has been revived, and, it is said, with much success,—from a quarter of an ounce to an ounce being given dissolved in a large quantity of gruel in the twenty-four hours.] We have hitherto treated chiefly of constitu- tional disorder, and have considered the local in- flammation only so far as it was connected with or dependent on the constitutional state. It is necessary however, to scrutinize the local affec- tions still further. So directly is the local dis- turbance dependent on the constitutional in the inc.p.ent stage, that if the latter be pn,mplly and vigorously treated, the former will very speedily subside without any local treatment being needed We have seen the local inflammation Thus sub^ side in rheumatism equally as in a first attack of RHEUMATISM. 35 mild gout, leaving as little trace of its visitation. It must be admitted, howwer, that such speedy decline is not the general character of this local affection. Notwithstanding the abatement of fever, some pain, heat, and swelling will continue to affect the joint for a longer or shorter time ; and in order to understand the treatment which this requires, it is necessary to bear in mind what was formerly stated respecting the change of character in the local inflammation. If on fever becoming subdued by the means directed, the local inflam- mation declines, no topical treatment whatever is needed, nor is it expedient that any should be resorted to. Decline of inflammation thus ob- tained affords conclusive evidence of disease being arrested at its source, and relapse need not here be apprehended; while, if the local inflammation be checked by topical remedies, its abatement af- fords no such assurance, and if the constitutional derangement be not thoroughly rectified, repeated renewal of the local inflammation with successive migrations from joint to joint will most probably ensue. But independently of this consideration there are other objections to the early use of topi- cal remedies which ought not to be overlooked. Repellent applications may remove inflammation from any particular part; but only to transfer it to some other, if not to the heart, stomach, or other internal organ. Local bloodletting would beget less danger of this kind, but neither is it free from objection. The inflamed part is ill suited to sustain the operations by which blood can be abstracted. We have seen leeches when applied to a rheumatic joint prematurely and without sufficient regard to the constitutional state, exasperate every symptom, and cause in- crease of inflammation both in the skin and cellu- lar membrane, ending in extensive sloughing, with troublesome ulceration, and followed by thickening of the ligaments with rigidity and con- tractions of unusually obstinate kind. So long as it is possible, therefore, to procure decline of local inflammation by the constitutional treatment, we consider it the better practice to abstain from to- pical remedies. When inflammation continues in the joint, however, after fever has been sufficiently subdued, thus manifesting its having passed into what we have distinguished as the secondary state, it then becomes necessary to regard it as a local disease, and by appropriate topical treatment to avert those ravages which its continuance would occasion. The means are cupping, leeches, warm fomenta- tions, poultices, cold lotions, modified according to the degree of inflammation, the sensations of the patient, and the effects produced. By such means, the local inflammation in this its secondary state may be so corrected as to prevent organic lesion, and preserve unimpaired the mobility of the joint. [The application of methodical compression around the affected joints by means of a flannel bandage is often productive of great relief. It was advised many years ago, and has been revived. (See the writer's New Remedies, 4th edit. p. 183, Philad. 1843.) It is especially serviceable where there is great effusion. It has been recommended, that the compression should be made by means of compresses covered with mercurial cerate j and that a position and attitude should he given to the limb that would be most favourable to resolution. An elevated position would certainly tend to prevent the engorgement of the parts. The writer has seen good effects from compression where it could be borne, and a simple flannel bandage is all-sufficient.] We would here impress, as we forme, ly did when treating of gout, the importance of an early renewal of motion in the affected joints, as indis- pensable for re-establishing their health and pre- serving their flexibility and power. From neglect of this, much protracted confinement and ultimate decrepitude continually result. On the subsidence of inflammation, the parts so lately disturbed are indisposed to motion, and some pain attends the early attempts at its removal. Yet leaving them at rest is not the means by which the power of motion is best restored. Exercise of the parts is necessary not only to restore those which have been morbidly affected to their healthy functions, but to preserve in due energy and activity the muscular apparatus by which they are moved. By exercise healthy circulation is maintained, effusion prevented, absorption promoted and flexi- bility preserved. By it, too, the muscles sub- servient to the motions of the joint are kept in a healthy and efficient condition. When, from too great apprehension of exciting pain or renewing inflammation, quiescence is too long continued, the ligaments and other parts surrounding the joints become rigid ; if these be kept bent, con- tractions take place, and the mobility of the part becomes permanently impaired ; while the several muscles, from want of exercise essential to the maintenance of their nutritive and healthy actions, progressively waste and lose power. This latter contingency is, we are persuaded, much more fre- quently owing to the continued inactivity to which the muscles are consigned than to any morbid action induced in them by the disease ; and as we before observed, so satisfied are we of the mischiefs resulting from long-continued rest after rheumatic inflammation, that we would in our own person much rather hazard any renewal of inflammatory attack, than suffer those derange- ments to proceed which spring from a state of inaction too long continued. [Capsular Rheumatism. — When rheuma- tism is seated in the lining membrane of the joints, and bursa? of the tendons, it is termed cap- sular. The parts most liable to its attacks are the feet and hands. It is recognised by the en- largement of the joints, which is circumscribed, owing to the distension of the synovial capsule with fluid ; and is thus distinguishable from the smaller and more diffused swelling of ordinary rheumatic fever. In its history, too, it differs generally, as Dr. Macleod (On Rheumatism, &c, London, 1842) has observed—affecting seve- ral joints, but commonly becoming more especially fixed in a limited number, and ultimately local- ized, and, in some cases, inducing permanent changes of structure, or disorganization. When death occurs in the acute stage, the joints are found to contain an increased quantity of syno- via : when the disease has been more prolonged, distensions and nodosities are seen, similar to what occur in gout. Deposits are often formed in i such cases on the cartilages of the joint,—which 36 RHEUMATISM. Dr. Macleod found to be of urate of soda, as in gout. In cases of old synovial rheumatism, how- ever, Dr. Chambers found them to consist of car- bonate of lime. At times, suppuration has been observed in the joint; but these cases are rare. Partial rheumatism of the joints, when of great intensity, is almost always of the capsular kind. This form of rheumatism is said to occur gene- rally in persons of feeble or debilitated constitution; or in the robust, after great and protracted men- tal or corporeal exertion. It is said, also, to super- vene on gonorrhoea and other venereal affections, but in the latter case almost exclusively, accord- ing to Dr. Macleod, " where long-continued courses of mercury have been adopted." It is very rare for metastasis to take place to internal organs, and when it does, it usually passes to the pleura or membranes of the brain, and proves fatal in a very high ratio. Of 81 cases of capsular rheumatism, recorded by Dr. Macleod, 47 occurred in men, and 34 in women. These were much more equally diffused over the different periods of adult age than acute rheumatism, and much more prone to affect persons under forty than genuine gout; at the same time, it appeared to be more the dis- ease of middle life than either rheumatic fever or muscular rheumatism; — from forty to forty-five years of age giving twenty-two out of eighty-one cases, or rather more than one-fourth, which is a much larger proportion than holds good with re- spect to either of the two others." The average duration of capsular rheumatism was found to be more than twice that of acute rheumatism. The general treatment, both internal and ex- ternal, is that recommended under Rheumatism and Gout.] What remains to be said respecting acute rheu- matism, and the sequela? occasionally left by it, will be more properly noticed in the division of the sub- ject which treats of the chronic form of the disease, to the consideration of which we shall now proceed. II. Chronic Rhkumatism. It would simplify the consideration of this form of the disease, if it were limited to that morbid condition to which analogy with the acute affec- tion discussed in the foregoing pages would jus- tify the name of rheumatism being applied. So many and various, however, are the derange- ments loosely classed under this generic term, that to give any history of the disease which should comprise the whole, would present a mass of con- fusion, if indeed it were not utterly impracticable. It has been too much the practice to pronounce as rheumatic every chronic pain of which the nature is obscure, or to which no other specific character is assigned. Practical writers have not overlooked this tendency; it is noticed by Heberden in the following very expressive passage : « Multi dolo- .es quibus nomina nondum propria imposita sunt, quanquam inter se distent, ex causis longe diversis orti, tamen ad rheumatismum pariter referuntur." In order to ensure as much clearness as possible in the following observation, it will be expedient to commence with that modification of disease which, presenting all the essential characters of rheumatism, differs from the acute affection already treated of only in being less violent in its symp- toms, and of longer duration. The distinctive characters of this malady are a febrile state of the general system, with more or less of pain and swelling in certain tissues and ioints. And in this, precisely as in acute rheuma- tism, the continuance of febrile action undermines the general health, while the local inflammation, however indolent, disorganizes the joints, occasion- ing eventual decrepitude. The pain and swelling of joints with progressive thickening of the liga- ments, and effusion in the several bursa?, sufficient- ly evince the morbid actions from which such effects result. But, coincident with these will generally be found in the instances now referred to, evidences of constitutional derangement suffi- ciently marked to denote that a plethoric and febrile state of the circulation is also present. A quickened pulse, some increased heat of skin, and a furred tongue, are in greater or less degree the invariable attendants of chronic rheumatism of the joints so long as the disease in them continues to advance. It, no doubt, occasionally happens that in the course of time all febrile symptoms disap- pear, and the morbid action in the joints ceases to make further ravage. In such cases there is no longer rheumatism, but only the disorganization produced by it; and the distinction is important. for where such ravages alone remain, so far as they are concerned, constitutional remedies can be of no avail, and any treatment, to be effectual, must have special reference to the local lesions by which the free motion of the limbs is impeded. In the larger proportion of cases, however, the disease is strictly rheumatic, that is, it consists of a constitutional derangement having a febrile character, and of a local inflammation seated in the joints. This condition may be, and frequently is, the sequela of acute rheumatism ; but it may be fully formed without any particular acute.attack having preceded. Cullen regarded it in the former light, as appears from his definition of arthrodynia being introduced as " rheumatismi sequela." In the definition itself he somewhat incongruously represents this as ensuing to violent sprains and luxations, though why the pains re- sulting from such accidents should be deemed rheumatic it is difficult to imagine. In this defi- nition, too, which ought to embrace every form in which chronic rheumatism presents itself, he states somewhat too positively the absence of fever and of swelling,— "pyrexia nulla, tumor plerumque nullus;" characters which do not apply generally to the disease, and which seem to have been introduced as an antithesis to the definition of acute rheumatism. This imperfec- tion obliged him, when treating of chronic rheu- matism, to enter into explanations rather at vari- ance with his own definition, and in the follow- ing passage he describes more correctly and intelli- gibly the transition of the acute into the chronic stage. "The limits between the acute and chronic rheumatism are not always exactly marked. When the pains are still ready to shift their place,— when they are especially severe in the night time, —when at the same time they are attended with some degree of pyrexia, and with some swelling, and especially with some redness of the joints the disease is to be considered as still partaking the nature of acute rheumatism. But when there is no degree of pyrexia remaining, —. when the RHEUMATISM. 37 pained joints are without redness, when they are cold and stiff,—when they cannot easily be made to sweat, or when, while a free and warm sweat is brought out on the rest of the body, it is only clammy and cold on the joints,—and when especi- ally the pains of these joints are increased by cold and relieved by heat applied to them, the case is to be considered as that of purely chronic rheuma- tism." If the character of chronic rheumatism is to be derived from the most numerous and pre- dominant instances, then we would say that the former of these descriptions is far more applicable to the disease, as generally met with, than the latter; for though all the phenomena recited as indicating the continuance of febrile and inflamma- tory action may not attend, it rarely happens that some or other of them are not present. As the former condition is capable of indefinite duration, for it may endure for years, and is hence strictly entitled to be called chronic,—it could not, where any distinction were made, be classed with the acute disease lately treated of; while, if it consti- tute any part of the chronic malady, a definition professing to characterize this ought assuredly to embrace it. Perhaps the more perfect representa- tion of the disease, if it be necessary or beneficial to make any such distinction, would be to include both descriptions under arthrodynia, subdividing this into sthenic and asthenic. In this view the sthenic arthrodynia is by far the most frequent form in which the disease presents itself; and, what is no less important, it is that which, if un- relieved or improperly treated, is productive of the greatest mischief and of most distressing results; for under it the disease both local and constitution- al, however indolent it may appear, is yet suffi- ciently active to continue and extend its peculiar ravages, deranging the general health, enfeebling and crippling the body through progressive disor- ganization of joints, and consequent wasting of muscles. In the asthenic form, the mischief is already done, and, however the body may suffer under the ravages sustained, there is no longer the active constitutional derangement inflicting further injury, which forms so essential a part of rheumatism. In the latter form there is little to do but support the general health, and remedy, as far as may be, the local lesions. But sthenic arthrodynia both admits of and demands more corrective treatment, the judicious, discriminating, and persevering use of suitable remedies being capable of accomplishing much, both in renovating health, and restoring power of motion to the still inflamed though rigid and contracted joints. With the consideration of this form we shall now pro- ceed. [The chronic form of rheumatism is often de- scribed as being frequently the sequel to the acute. This does not accord, however, with the experience of the writer. So far as his observa- tion has gone, the subjects of acute rheumatism rarely suffer from the chronic form ; and, on the other hand, persons who are constantly more or less crippled by chronic rheumatism may pass through life without suffering from the acute.] It is a prevailing impression that a chronic disease cannot be inflammatory. How this origi- nated it is needless to conjecture; but, however the misconception arose, it is a familiar truth that | the term chronic conveys to most minds not the simple idea of duration, which alone it expresses. but something the opposite of inflammatory; some state to which the treatment proper for in- flammation cannot be applicable. The pure chronic rheumatism of Cullen as described in the foregoing extract, is unquestionably of this latter character; but as the disease comprises, in addition to this, the subacute or sthenic condition also noticed by him, it is necessary to understand the term chronic, when its application is thus extend- ed, in that restricted sense alone which rightly belongs to it. Practitioners who are accustomed to regard chronic rheumatism as asthenic, and to treat it accordingly, are little aware of how long a deci- dedly inflammatory character may attach to it. Years may elapse, yet a distinctly febrile state, indicated by its appropriate phenomena, prevail, accompanied with evidences of disorganizing in- flammatory action on the joints. And so long as this state endures, is there progressive deteriora- tion of general health, and increasing structural derangement of joints. It gratifies the writer of this article to see this fact unequivocally stated by Dr. Elliotson, in his excellent clinical lectures de- livered at St. Thomas's Hospital. He acknow- ledges the inflammatory character, and also the great length of time for which this may be retained, specifying this form of rheumatism as active in contradistinction to the term acute, which in its strict sense could not apply to it. The same cha- racter was long ago indirectly recognised by Sagar, when, in his definition of chronic rheumatism, he stated the blood drawn to exhibit a buffy crust. In this form, however subdued the symptoms may be, the characteristics of rheumatism, as they have been exhibited in the acute disease, are distinctly traceable. There is a febrile state of the general constitution, and more or less of inflammatory action in the joints; and the principles of treat- ment are precisely similar, though they require to be modified in their application so as to adapt this to the derangements, both constitutional and local, which need relief. It will assist in comprehend- ing the real nature of this form of the disease to bear in mind what was formerly stated in treating of relative plethora. Certain delusive appearances were then noticed, as misleading practitioners from a right conception of the state of circulation or condition of health existing; and to similar delu- sions has it been owing that the febrile character of active or sthenic arthrodynia has been so fre- quently overlooked. An apparently feeble and compressible pulse induces the persuasion of de bility ; the enfeebled powers of the body sanction the conclusion ; and relief is sought from a class of remedies which, in such case, cannot give other than transient relief, if, indeed, they do not aggra- vate every symptom. Were we sure that the doctrines of plethora formerly illustrated were rightly understood, we could at once close the discussion of the constitutional state prevailing in sthenic arthrodynia, by representing it briefly as that of relative plethora. It differs from the con- dition formerly described as relative plethora, only in having the local inflammations with their con- sequences superadded. In order to determine ac curately this state of constitution, it is necessai" 38 to judge, not from any one indication, but from that assemblage of evidences which, when collec- tively present, cannot mislead. The pulse, if alone trusted to, may deceive, at least where the practitioner is not on his guard against the delu- sive lowness of pulse which belongs to incipient plethora, or is unacquainted with the peculiar changes which the pulse undergoes tohen the con- gestive state is passing into that of febrile action. Though apparently low in force, it yet evinces some resistance to pressure, and is more or less quickened ; the skin, too, is hotter than natural, and the tongue is white and furred. The gastro- intestinal membrane will also be found charged with redundant mucus, such as it generally se- cretes under febrile action. When all these phe- nomena are present, and especially when they are accompanied by evidences of local inflammation in the joints, no doubt need be entertained either of the nature of the disease, or of the principles of treatment. In this form of disease, then, it is obvious that the indications of cure are in no respect different from those which have been already shown as applying to acute rheumatism, namely, to subdue fever, and remove local inflam- mation. And the rationale of the practice suited for fulfilling these indications will be clearly per- ceived by those who have taken the trouble to comprehend the doctrines respecting the patho- logy of the circulation advanced in the article Plethora. The constitutional state of sthenic arthrodynia bears the same relation to relative plethora that the acute form does to absolute; and in the prin- ciples of treatment laid down for the correction of relative plethora, with its concomitant disturbances, will be found the best guidance for conducting with precision and effect that of active chronic rheumatism. On the same principle as in acute rheumatism, it is the constitutional state which demands the first attention ; for, unless this be radically corrected, all efforts to cure permanently the local ailments must fail, or be only of tran- sient effect. In treating the constitutional dis- turbance, it is necessary to bear in mind that it is connected with relative rather than absolute ple- thora; that, consequently, the derangements exist- ing are more complex, and that the practice must hence embrace considerations which it was not necessary to insist on particularly in discussing the acute disease. In acute rheumatism, active bloodletting was directed ; the object being not only to reduce plethora, but to make speedy im- pression on febrile action, in order to arrest prompt- ly the injuries which unrestrained continuance of this would occasion. In the more chronic form it is necessary to diminish plethora, but not equally so to make at speedy impression on febrile action. This lattei requires to be regulated, but not ex- tinguished ; for some increased energies of circu- lation are absolutely necessary for correcting the concomitant derangements of function produced by defective capillary circulation. To restore the impeded circulation of the capillaries, and renew the secretory and excretory processes of which they are the agents, seems to be the final cause for which febrile action is instituted; it is assur- edly the end which it often attains, and hence, when natural fever fails to accomplish it, we are RHEUMATISM. ~customed to institute an artificial fever through the operation of mercury to effect the purpose. This, however, is not to be forced; .t require. time for safe and salutary progress: m.nute ves- sels long obstructed cannot be all at once rendered pervious and efficient for the discharge of func- tions long disused; and hence, in treating the febrile state of chronic rheumatism, the practice though corresponding in principle with that of acute, must be much less energetic. Bleedings must be of smaller amount and at longer inter- vals; a free state of excretion must be moderately but steadily maintained; and mercury must be employed for that renewal of function in the ca- pillary vessels and their secerning extremities, which the powers of the constitution, unaided by mercury, are inadequate to accomplish. It will be recollected that in relative plethora the redundancy of blood results more from its im- perfect appropriation than from absolute excess; and that correction of this state requires, not only that the larger vessels be relieved from the load which oppresses them, but that the aggregate capa- city of vessels be enlarged by renewal of the sus- pended activity of the capillaries, and also by pro- moting the natural expenditure of blood through the several secretions and excretions. These are the curative effects of febrile action; they consti- tute also the beneficial operation of mercury on the system, and on regulating them conformably with the views here displayed will the success of medical practice in a great measure depend, not only in this but in many other diseases. In the diseased state now under consideration, the first object should be to relieve the oppressed circula- tion, and thus arouse the energies of the system by taking away some blood ; and in conducting this part of the treatment, judgment and discrimi- nation are so requisite, that, even at the hazard of being deemed unnecessarily minute, we must dwell on the several circumstances from which any guidance can be derived. If, with the general evidences of plethoric op- pression and febrile action, the powers of the con- stitution be very low, and the pulse very feeble, it may be advisable to suspend for a while direct depletion, and to trust to purgatives. It may, in such case, be even expedient to employ gentle stimulants in order to arouse the dormant energies, and enable them to bear direct bloodletting ; this being the end to which the use of stimulants should in this stage be directed. The necessity for this degree of caution, however, is not of most frequent occurrence. Much more generally may the curative treatment commence with small bleed- ings ; and in these it should never be forgotten that the object is not to make impression on the moving powers, but to withdraw a portion of the circula- ting mass, and this with a view of arousing the natural powers to the discharge of functions re- quired for the re-establishment of health. Small bleedings here suffice; and the extent of six or eight ounces will best answer the end designed. According as power increases, larger bleedings will be borne; but beyond twelve ounces it is rarely necessary to carry them. In general, even i the first portions of blood drawn will be buffed if | not cupped; and under such circumstances the i pulse, if previously low, will be founj to ris€ RHEUMATISM, 39 under bleeding. As was before remarked, a soft pulse is no contra-indication of bloodletting; for we continually find buffy blood and increase of power after venesection, where the previous soft- ness and feebleness of pulse would, to unreflecting observers, appear to prohibit all direct depletion. This deceptive character of pulse is too often allowed to influence the practice even in acute rheumatism; yet it has been so often the subject of remark, that practitioners ought to be fully aware of it. Dr. Gregory, who in the treatment of acute rheumatism did not employ bloodletting indiscriminately, nor deem it essentially necessary, but who trusted rather to sweating as the prefer- able evacuation, used to acknowledge that he had been obliged to have recourse to bleeding after several weeks' duration of disease, where he had at first been apprehensive of employing it from the smallness and apparent debility of the pulse; and that after bleeding, the pulse rose and disease sub- sided. This is not peculiar to rheumatism, but a general fact connected with derangement of circu- lation, and worthy of attention in many diseases. The explanation of it has been fully and clearly given in the article Plethora ; and if the prin- ciples there inculcated be duly regarded and dis- criminately applied, there will be little hazard either of bloodletting being withheld where it is needed, or of its being carried to any injurious extent. Next to bloodletting, the most important evacua- tion is purging, which requires to be regulated both according to the degree of febrile action present, and to the state of the bowels as manifested by the stools. In proportion as fever is active will the free use of purgatives be required, and saline ca- thartics be needed in aid of those which more pe- culiarly deterge the mucous membrane of its mor- bid secretions; but so long as these continue dark, slimy, and unnatural, must suitable purgatives be assiduously employed. Pills of calomel, colocynth, and antimony, with occasional doses of sulphate of magnesia and senna, are the most effectual means of adequate purgation. According as ac- tive fever prevails, as evinced by a quick pulse, hot skin, and white or furred tongue, salines with antimony and colchicum, assisted by antiphlogistic regimen, should also be conjoined. If under this treatment febrile action does not speedily abate, and local inflammation subside, mercury will be required, and for purposes similar to those for which its use was directed in acute rheumatism. According as fever is active will calomel and opium be necessary, for the proper administration of which no further instruction can be here needed, it being only necessary to observe, that as the morbid actions requiring correction yield more slowly than in acute rheumatism, a more slow and cautious administration of the remedy is here expedient. The direct agency of the medicine is to excite freer circulation in the capillary vessels, by which the larger vessels be- come relieved, both through the increased capacity thus given to the vessels through which the mass of blood circulates, and the increased expenditure of blood in the several secretions and excretions thus promoted. Whoever bears these facts and principles in mind, will experience no difficulty in regulating the administration of mercury in this or any other disease. In many cases, however, febrile action, though sufficiently manifested by its appropriate pheno- mena, is less developed than in those just referred to. The pulse is feeble and irregular, the several secretory and excretory functions are inactive, and the whole frame displays a deficiency of power. Here stimulants are needed, and the most effectual for arousing the dormant energies is mercury. The milder preparations in small doses, repeated at intervals, are what should here be employed. The compound calomel pill, blue pill, hydrargy- rum cum creta., are the remedies chiefly in use where a slowly alterative effect is desired. In old and obstinate cases minute doses of the oxymu- riate have effect when other preparations fail When the latter is resorted to, decoction of sar saparilla is beneficially combined. Whenevei mercury is employed for such purposes, it is highly necessary to watch closely the state both of the circulation and of the bowels. If under its use the arterial system becomes excited, and the pulse rises, becoming full, hard, or resisting, blood should he taken ; and as mercury, when so administered, promotes the intestinal excre- tions, these should be assiduously evacuated by suitable purges, which in such case serve the double purposes of removing from the intestines a source of irritation, and of maintaining the excretories in an active exercise of those functions which so materially assist the curative process. Under the foregoing treatment part of the local inflammation will subside without any topical remedies being applied. But as these inflamma- tions have long reached the secondary stage, and as local derangements, such as were formerly no- ticed, have become more or less established, the local treatment suited to the special circumstances of each case is here indispensable. According as the local inflammation presents an active charac- ter, cupping or leeches will be required ; and by these, with fomentations, or with cooling and j sedative lotions, much impression may be made. Blisters, too, in time, are of much effect, especially where the bursa? are loaded with glairy effusion, the ligaments thickened and rigid, and the whole joint enlarged. To these changes all the joints are liable ; they peculiarly occur in the wrists, where they materially impede the motions of the hands, rendering the patients very helpless. These swellings, when accompanied with heat and red- ness, require leeching and cold lotions ; other- wise, repeated blisters are the means by which the enlargement can be best reduced, the effusions absorbed, the ligaments attenuated, and the flexi- bility of the articulations restored. In the inter- vals of blistering, stimulant embrocations are very serviceable; and frictions, especially the kind of manipulation termed shampooing, are of much avail. In the inveterate cases which continually occur in practice, it is not any one remedy that can be relied on. The combined agency of all is re- quired, and they should be assiduously employed in such succession and alternation as enlightened judgment may direct. By a judicious and steady use of them many a case, apparently hopeless, 40 RHEUMATISM. may be restored to the enjoyment of good general health, and to considerable freedom of the affected limbs. Throughout the whole course of treat- ment warm bathing is signally beneficial, as is largely attested by the records and daily expe- rience of the noble institution to which the writer of this essay is indebted for much practical know- ledge—the Bath Hospital. It cooperates with the constitutional treatment to improve general health, promoting a free circulation in all the capillary vessels, and calling into renewed activity the highly important excretory functions of the skin, while its special effect on the pained and crippled joints is eminently salutary. For the latter pur- pose, pumping on the limbs, as it is termed, that is, directing against those affected a stream of tepid water, impelled with such force as to exert a mechanical influence on the part, is oftentimes a very powerful auxiliary. Even when general warm bathing is not admissible, this partial appli- cation of wa^m water may be used with much advantage for the relief of local ailments. Subsidiary to these several means, one of the most effectual aids for restoring motion to rigid or contracted joints is the persevering endeavour to render them flexible by assiduous exercise ; and the more this can be promoted through the appro- priate muscles of the affected joints, the greater will be the benefit resulting ; for the muscles pre- viously wasted will thus recover bulk and strength, and through renewal of exertion will prove a most valuable instrument both in preserving and ex- tending any power of motion that may be gained. Frictions and shampooing are a sort of passive exercise, and through this, as well as by pro- moting absorption and inducing a freer circula- tion in the extreme vessels, their effect on en- larged or rigid joints is considerable. But even where, from great rigidity and extreme muscular feebleness, the joints are incapable of being exercised by their own proper muscles, the advantage derivable from passive exercise is not to be despised. Frictions and shampooing may lessen rigidity, so as to give more effect to the feeble muscles in their languid efforts. When the wrist and finger joints are affected, the parties may materially benefit themselves by moderate but continually renewed attempts to move the joints of each hand by means of the other. The joints may resist for a long time, but this should not discourage, and the slightest renewal of mo- bility should be hailed as the sure harbinger of further improvement. It is needless to urge this further. The principles are obvious, the effects proved by ample experience ; and at all events perseverance in such endeavours, however little it may in extreme cases accomplish, holds out to the rheumatic cripple the only hope of recovering mobility in joints rendered inflexible by the effects of rheumatic inflammation. Attempts to restore mobility in such cases by internal medicines alone, is worse than fruitless. They may correct constitutional derangements where these coexist and, by restoring general health, prevent further mischief; but they can have no effect in renew- ing either mobility or power to limbs so affected. It has been shown that the secondary inflam- mation of acute rheumatism may survive the cause in which it originated. In lit" **— local inflammation of chronic rheumatism may continue, although the febrile state which nurtured and aggravated it may have wholly subsided ; and, further, the ravages of rheumatism in the joints may remain when all fever, as well as local in- flammation, whether primary or secondary, has ceased to exist. Chronic rheumatism, therefore, may be said to present three conditions which de- serve to be practically distinguished; — active fever with local inflammation ;—inflammation un- accompanied with fever ;—and structural derange- ments of joints unattended by either fever or local inflammation. Each of these conditions requires to be treated on principles applicable to its pecu- liar state; and any treatment adopted merely on account of its being specifically suited for rheu- matism, must, if indiscriminately applied, be pro- ductive of much mischief. There is another diseased condition often con- sequent to rheumatism, namely, a loss of nervous energy, which constitutes a modification of par- alysis ; but this demands a separate consideration, which belongs rather to paralysis than to the pre- sent subject. The first condition of chronic rheumatism, or that which comprises both active fever and local inflammation, has been sufficiently discussed, The next in order is where the local inflammation, with the attendant pains and other derangements, endures after fever has subsided. This form also is of frequent occurrence, and it differs from the former in not requiring general bloodletting for its cure. Local depletion and occasional blisters' constitute the principal topical treatment; and mercury with sarsaparilla and other such auxili- aries, is the chief agent for inciting the constitu- tional energies to cooperate in the cure. It is this form of the disease that has misled even intelli- gent practitioners into pronouncing that general bloodletting is not necessary in chronic rheuma- tism. Dr. Elliotson in his admirable clinical lec- tures has expressed himself of this opinion, and declared that he has relinquished general bleeding in active rheumatism, unless when some internal inflammation coexists. That in many such cases the treatment recommended by him, namely, local bleeding, colchicum, and mercury, will succeed without general bleeding, we were well aware; but we are no less assured that in very many it would prove very tedious, if not wholly fail. We consider, therefore, that Dr. Elliotson has stated this opinion somewhat too broadly ; and that on reconsideration he will himself admit that the criterion for employing the lancet should be, not the presence of an internal inflammation, but such degree of plethora and febrile excitement as in itself demands direct depletion, independently of all coexisting local derangements. Topical bleed- ing, low diet, colchicum, and mercury, form a combination of influences which has great power m subduing febrile and inflammatory action ; but if plethora exist to a certain extent, even their united agency will be insufficient, unless direct depletion be conjoined. And in such case it re quires to be borne in mind, that, as has been already explained, the operation of mercury is not devoid of danger. When there is l„ca, f'? " mation without plethora or fever, the treat men* RHEUMATISM. 41 Even where plethora and fever exist only in slight degree, it may also succeed, although the progress will be slower than when venesection is conjoined. But when plethora and fever exist to any extent, then, even though there be no internal inflamma- tion, general bleeding ought unquestionably to form part of the treatment. Chronic rheumatism has been sometimes dis- tinguished into hot and cold,—the hot being the active rheumatism of Elliotson, the cold the arthrodynia of Cullen. In the last, various stim- ulants are of much avail, and for the relief of such disease they should undoubtedly be resorted to. It is to be hoped, however, that their misap- plication to acute or to any active rheumatism as the appropriate remedies, has passed away, or is confined only to ignorant empirics. It illustrates the difficulty of adapting treatment explicitly to the name of a disease, or even to special degrees of it, that there are modifications of active rheu- matism in which even stimulants, cautiously ad- ministered, are not only safe but beneficial; and this circumstance confirms the necessity of all medical treatment being regulated, not by express rules, but by those principles from which all rules ought to emanate, and to which they ought to be subservient. It would be vain to enumerate the various stimulants which have obtained character for the cure of cold rheumatism. The principal are essential oils drawn from resinous substances, such as turpentine ; various balsams and gum-resins ; the latter either in substance or in simple or am- moniated tinctures ; sudorific decoctions ; electri- city. Any of these may benefit according as the general constitution is prepared for their operation, or as the special ailments may require. If there be no plethoric or febrile state present, their use will at least be harmless, if not beneficial ; but should the case be such as to need depletory treat- ment and the operation of mercury, then must the use of such stimulants as are now named be watched with great caution. Warm bathing and active exercise are among the unexceptionable and most powerful means of relieving chronic rheumatism. The local treat- ment formerly directed for the sequela? of acute rheumatism also requires to be assiduously em- ployed. There are some affections generally regarded as rheumatic, which, however connected with rheu- matism, seem to depend chiefly on a morbid condi- tion of particular nerves. Of this kind are scia- tica and lumbago, both of which differ so much in their symptoms from acute rheumatism, as scarcely to admit of their being classed under it. A mere error of arrangement, however, is of little consequence, as the same principles of treatment apply to all. If the state of constitution be such as to require for its correction bleeding, purging, colchicum, and mercury, these remedies must be employed, else the local affection will not readily yield. That sciatica arises from some lesion of the sciatic nerve or its investments, most practi- tioners are agreed. That this lesion results from a primary congestion or inflammatory action, seems evidenced both by the whole train of symptoms, and by the treatment most successful in giving relief. Vol. IV. — C r> * When there is only the local affection to treat, repeated cupping or leeching, and blistering, with the warm bath, and a cautious return to exercise, will do much to effect restoration. Stimulant and sedative embrocations too, are occasionally of ser- vice. In lumbago, though the spinal nerves affected are less distinctly indicated, yet the character of the pain marks it as more neuralgic than rheuma- tic. Free cupping and the general treatment of acute rheumatism will best succeed in relieving this disease. But there is a form of neuralgia occasionally attendant on rheumatism which causes much suf- fering, and which does not seem to be generally understood. It occurs in paroxysms of great in. tensity, attended with a severity of pain which few can patiently endure. This may arise ere the febrile state has thoroughly subsided; and this circumstance is apt to mislead, for a continuance or removal of inflammation is thus apprehended, and depletory treatment is pursued, under which the disease is aggravated instead of relieved. The character of this affection is best denoted by the suddenness of the painful accessions. The nature of the pain, too, so different from that which at- tends inflammation, seems to distinguish it. For this affection the most certain and effectual reme- dy is iron ; but it must be largely used, and as- sisted, if necessary, by full doses of opium. The carbonate is the best preparation, and this should be given in doses of two drachms three or four times a day. By administering it with equal parts of treacle, as directed by Dr. Elliotson, its consti- pating effects are obviated. Should opium be re- quired, it should be given in full doses, and the best preparation for the purpose is Battley's seda- tive solution, of which from thirty to ninety min- ims may be given at bed-time without any sinister effect resulting. Under this treatment it may be necessary to purge occasionally with the common senna draught, which is sensibly improved by the addition of half a drachm of spirit of ammonia. In the progress of rheumatism the chest is apt to become affected with pain and great dyspnoea, the distress being referred to the lower part of the chest, and described as if the point of the sternum were drawn back to the spine. This arises from the extension or translation of rheumatism to the diaphragm. The means of relief are bleeding, purging, and colchicum, with calomel and opium. So soon as the gums are touched, the distress finally ceases. One of the most important affections connected with rheumatism is that in which the heart or its investments becomes the seat of rheumatic inflam- mation. This inflammation may be of the most acute kind, constituting complete carditis or peri- carditis ; or it may be only such increased action of blood-vessels as ultimately leads to hypertrophy. For the acute attack the most active treatment is required ; full bloodletting, purging, antimony and colchicum, but above all the early and decisive operation of calomel and opium. If the latter be not speedily and effectually obtained in subservi- ency to bloodletting, this will be required to such extent as to render recovery extremely doubtful, sink greatly the powers of life, and occasion a very tedious convalescence. Some interesting cases of 42 RHEUMATIC M. rheumatic pericarditis have been recently pub- largement of joint, to which it is so prone presents lished by Dr. Davis, the senior physician of the much more ofthe charac er ofgouthaofrheu ._ by _. Bath hospital. He seems, however, to have trusted to general antiphlogistic regimen, without calling in the aid of mercury. The principles advocated in this article display the merits of mer- cury as an adjuvant; and the experience of the writer fully confirms their truth and practical uti- lity. But independently of this acute seizure there is continually found in connection with rheumatism inordinate action of the heart, with evidences of actual enlargement or hypertrophy of that organ. The treatment of this affection, we can from much experience say, is best con- ducted on the principles inculcated in this article. Moderate bleedings are indispensable, the blood being almost invariably buffed and cupped. In judging of the state of circulation, the pulse at the wrist would mislead, for it may be soft and compressible even when the action of the heart is tumultuous. The carotid should here be exa- mined as furnishing a more certain criterion. Free bowels and antiphlogistic discipline are indi- cated by the same necessity which calls for ab- straction of blood. Mercury with opium is also required to produce its specific effects, by which alone the morbid action can be effectually or per- manently subdued. The use of this requires to be cautiously conducted, for its slowest operation is that which is here most beneficial. The morbid condition is generally of slow formation ; the changes wrought are not of a nature to be sud- denly rectified; and attempts to accelerate the case beyond what nature permits, would beget mischief and lead only to disappointment. Cup- ping and leeching over the heart are valuable aux- iliaries, and blisters are occasionally needed. In fine, when inflammation both general and local is allayed, and the action of the heart still continues inordinate, or is too easily excited, the application of belladonna to the side, in the form of plaster, affords a valuable means of quieting the heart's motions, and of procuring rest from a disturbance which is always distressing. [In this as well as in every form of rheumatism, the iodide of potassium, given in large doses, has been greatly extolled. (New Remedies, 4th edit. p. 396, Philad. 1843.)] By the cautious adaptation of such means, and steady perseverance in their use, the disturbance of heart here treated of may in time be effectually relieved. Time, however, is required, for the dis- ease yields slowly; and though impression be made on it by the early procedures, months may elapse ere perfect tranquillity of circulation can be restored. The patience, however, which can iwait this result, and pursue steadily the means of accomplishing it, will be amply rewarded. There is one more form of rheumatism which ,equires to be noticed, namely, that which is called rheumatic gout; and so far as a name is con- cerned, this appellation, though only a popular lerm, is not misapplied. So much has this disease in common both with gout and with rheumatism, that it is scarcely possible to regard it otherwise than as a hybrid malady, in which the elements of both these diseases coexist. Its accession cor- responds most with rheumatism; its ravages have a greater resemblpnce to those of gout. The en- matism. Dr. Haygarth has described this disease, and proposed to denominate it nodosity of the joints. Of its history and treatment there is lit- tle to be said beyond what has been already ad- vanced under the heads of gout and of rheumatism. It is more frequent in women than in men. Its commencement is often marked by active fever, and in proportion as this is disregarded or inade- quately treated, are its ravages more severe and inveterate. But in many it advances by a slow and insidious progress, disorganizing the joints without materially deranging the general health. The local swellings long retain the character of active inflammation, being hot, red, and painful. They in general surround the whole joint, and, so far as mere touch can determine, they seem to arise from a general enlargement of all the struc- tures constituting the joint. It seems strange that the structures actually enlarged have not been long since ascertained by actual dissection ; yet we are not aware of any account of them, founded on anatomical examination, having been published. In 1805 Dr. Haygarth had not met with any such account, as appears from the following paragraph of his treatise: " In this disease the ends of the bones, the periosteum, capsules, or ligaments which form the joint, gradually increase. These nodes are not separate tumours, but feel as if they were an enlargement of the bones themselves. This point might be anatomically ascertained without any difficulty or doubt." The disease, according to Dr. Haygarth, does not appear to shorten life; the first patient whom he saw so affected reached the age of ninety-three. As to treatment, this must be regulated accord- ing to the state of constitution and local symp- toms, and on the principles inculcated in this arti- cle. By local treatment much relief may be ren- dered. Frequent leeching has much effect in abating heat, swelling, and pain. In the purely chronic stage, successive blisters contribute much to reduce swelling and restore flexibility. As the hands particularly suffer from this malady, it be- comes necessary to blister each finger separately, and even each joint; a process, which, however irksome, is yet ultimately recompensed by the in- creased power of using the hands which may he thus obtained. [Under the name Rheumatic Dermalgia, Mr. Beau (Note sur la Dermalgie, in Archiv. general. de Med. x. ii. 120, Paris, 1840) has described an affection characterized by the following symptoms. The head and lower extremities are the parts most usually attacked, but the pain does not remain in one place, often changing its seat gradually, and wandering from place to place. Two kinds of pain are experienced, the one enduring, the other intermittent and severe, resembling the prick of a pin or an electric shock, and recurring about every half minute. The enduring pain is often little more than an exaltation of the natural sensibility of the skin. Friction of the part with the finger, or with the patient's dress, always augments the pain; and if there be hair on the affected part very severe suffering may be produced by passing the hand over the hair. v Rheumatism of the skin commonly alternate! RICK with that form of the disease, which affects the muscular and fibrous tissues. Its usual duration is a day or two, after which it gradually subsides. It is said to be a more frequent occurrence among men than women, to be induced by damp, cold, and the ordinary causes of rheumatism, and, in general, not to require much treatment.] E. Barlow. [Robley Dunglison.] RICKETS.—Rhachitis, Rachitis. The term rhachi/i.i was derived by Glisson from the Greek jidxi (spine), because this disease affects, in an especial manner, the spinal column ; but he ac- knowledges that he was induced to adopt this term from its near resemblance to rickets, a word by which the malady was commonly known in England even before his time.* The work of Whistler, and the remarkably. clear and full ac- count of rickets afterwards given by Glisson and his associates Bate and Regemorter, have procured a currency for their opinion that the disease made its first appearance in the western parts of England towards the middle of the seventeenth century, and have obtained for rickets among continental writers the designation of the English malady, (Morbus Anglicus, Maladie Anglaise, Englische Krankheit.) That rickets was never distinctly described by any medical author before the times of Whistler and Glisson, we readily admit; but that it was of such recent origin as the period stated above, we conceive to be quite inconsistent with the several terms in the Greek and Latin languages denoting deformity and decrepitude of the human body, and with the instances recorded in ancient history of persons so afflicted who were distinguished in various departments of letters and even in arms. The essential characteristic of rickets is a soft- ening of the bones ; but the exact change which takes place in their structure, and the general symptoms by which this alteration is attended, are considerably different at different periods of life. Taking the term rhachitis in this extended sense, to which perhaps osteomalakia would be more properly applied, the disease may be divided into two species;—1st, softening of the bones of chil- dren, or common rickets ; 2d, that of adults, mol- lifies ossium, or osteo-sarcosis. Softening of the bones, like scrofula, is not unfrequently met with among the inferior animals. Thus Lordat dis- sected a rickety monkey; Bicherod found soften- ing of the ribs of an ox (Act. Maris Balthici, 1707) ; Dupuy describes the skeleton of a rickety horse (Dupuy, De l'Affection Tuberculeuse) ; Mason Good (Study of Medicine, vol. v. p. 327) asserts that rickets occurs in the lion ; and Comber has written a dissertation on the disease as it ap- pears in sheep. (Letter on the Rickets in Sheep. Lond. 1772.) But to descend from the researches of the learned to the information of those who are observant of the manners and diseases of our domestic animals, curvature of the bones and swelling at the joints are not unfrequently seen in whole broods of young geese and ducks, when * David Whistler, Dissertat. Inaugur. de Morbo Puerili {hnglor. dicto "The Rickets." Lugdun. Batavor. 1645. This work, which preceded that of Glisson, is now ex- ceedingly rare: a copy still exists in the Bodleian Li- brary. ETS. 43 they have been continually exposed to cold and wet. The same affection is met with in young pointers, and more frequently in greyhound pup- pies, when kept in confined and cold damp ken- nels. In pigs, the same disease is in some places named krinckets ; its causes are cold and moisture, and bad nourishment; and for its cure baths of hot grains are used, oily frictions, nutritious food, and removal to a warm and dry place. I. Rickets or Childhen. 1. History.—This disease rarely appears before the seventh month, and most commonly does not declare itself until the child first begins his attempts to walk, or until he suffers from the severity of the first dentition. Rickets has also been observed at birth, and in the foetus : of the former Glisson (De Rachitide, p. 178), Henckel (Abhandl. Chi- rurg. Oper. Th. ii. p. 14), Klein, and Lepelletier (Maladie Scrofuleuse, Paris, 1830), have given examples; and of the latter Bordenave (Mem. de Mathemat. et Physique, torn. iv. p. 545), and Pinel.-f- [Of 346 rickety children observed by M. Guerin, (Gazette Medicale de Paris, pp. 433, 449, 481. Paris, 1839,) 209 had been attacked with the dis- ease at from one to three years old ; three cases only had occurred before birth ; and 34 at from four to twelve years of age. Girls appeared to be more liable to it than boys. Of the 346 indivi- duals referred to above, 198 were females, and 148 males. (Guersant, art. Rachitisme, in Diet, de Med., 2de advantage. 58 RUBEOLA — RUPIA. appears that there died, from December to October 1831, of measles 532, of small-pox 436, and during the same period in 1832 the number of deaths were, of measles 508, of small-pox 532; making a total of measles 1040, of small-pox 968. Morton has given a very highly exaggerated account (Append, ad Exer. de Morb. Acutis, p. 127,) of the mortality during the epidemic of 1672, when he says the deaths from measles were three hundred every week; whereas it appears, from the public bills of mortality, that the whole number of deaths for that year by measles amount- ed only to 118. (See paper by Dr. Dickson in Med. Obs. and Enq. vol. iv. p. 256.) Sequelae.—Measles are very frequently follow- ed by a train of symptoms indicative of serious pulmonary lesions, very generally by a distressing and tedious cough, by chronic bronchitis, chronic pleuritis, pneumonia,* tubercles and phthisis ; chronic diarrhoea, generally of an inflammatory character, sometimes harasses and exhausts the patient; ophthalmia, ear-ach, and running of the ears, occasionally also supervene. There are several cutaneous affections apt to appear after measles; amongst them is a very troublesome eruption of inflamed pustules, sometimes termina- ting in ulceration. In a few instances gangrene of the inside of the cheeks, gums, and lips, in the horrid form of cancrum oris, has been observed ; in other instances the mortification has affected the vulva. Anasarca has been known to appear after measles, as it very often does after scarlatina ; but this is so rare an occurrence, that where anasarca is found, and said to have been preceded by measles, there is much reason to suspect that the previous disease was scarlatina. (Frank, torn. ii. p. 372, op. cit. Guersent, Diet de Med. art. Rougeole.) Dr. Harty, who has had extensive op- portunities of observing this disease, informed the writer that he has very frequently found during convalescence from measles that the pulse became unusually slow, about forty or fifty beats in a minute ; but it did not appear to be connected with any thing unfavourable in the condition of the patients, whose recovery was uninterrupted. William F. Montgomery. RUPIA, from j>i*os, sordes, may be character- ized as an eruption of flattened and scattered bulls, each surrounded with an inflamed areola; the bulla? filled with serous, purulent, sanious or dark bloody fluid, and succeeded by thick dark-coloured scabs covering unhealthy ulcerations. Bateman and Biett describe the varieties of rupia under three species or heads, viz. rupia simplex, rupia prominens, and rupia escharotica. The last of these, rupia escharotica, being the same disease as gangrenous or infantile pemphigus, and as such already fully described in the article Pem- imiigus ; the other two species, rupia simplex and rupia prominens, alone demand a place here : moreover, as these differ from one another merely * Laennec thinks that the suffocating orthopncea which sometimes very suddenly carries offyoung children after measles is produced by an idiopathic redoma of the lungs. In the greater number of cases examined after death by the writer, the morbid alteration existing was the condensation of the pulmonary structure ordinarily found as the effect of pneumonia. in degree of severity, they may be comprised under one general description. The bulla? of rupia are observed most often on the lower extremities, but are also frequently seen on the loins, the upper extremities, and about the shoulders. They are always few in number, and are generally scattered at some distance from one another. In the mild form, (rupia simplex,) one or more oval bulla? arise with little or no premoni- tory redness of the skin. These bulla? are flat- tened, and are filled with a sero-purulent fluid, and seldom exceed a sixpence in size. After the lapse of a few hours from their formation, they become partially flaccid ; the contained fluid grows muddy and puriform, and dries into a dark-brown scab, thick in the centre, and thin towards the circumference. Around the scab there is a dusky red areola, the cuticle covering which is slightly raised or separated from the true skin, and con- tinues all round with the thin edges of the scab. The latter is in general easily removed, or falls after a few days, leaving an unhealthy-looking ulceration of the skin, which either becomes crusted with a fresh succession of scabs, or heals, leaving a dark purple mark. In the aggravated degree of the disease, (rupia prominens,) a circumscribed inflammatory redness precedes the formation of the bulla?. The bullse rise slowly, and, instead of serous fluid, contain purulent matter or a mix- ture of purulent matter and blood, which consti- tutes the blackish fluid already mentioned as some- times found in the bulla?. The contained fluid dries into a very dark-coloured scab, which covers a deeper ulceration, and is surrounded by a widei inflammatory areola than in rupia simplex, and as the ulcerated surface is continually secreting pus, and at the same time enlarging in circum- ference, the scab is increased by successive layers, each wider than the preceding, and at length, at the termination of ten or twelve days, acquires a conical shape similar to a limpet-shell, sometimes extending at the base to the size of a dollar in area, and protruding in the centre an inch above the surface of the skin : hence the name of this variety of the disease — rupia prominens. This scab is superficial, and if removed is either replaced by a fresh scab, or leaves exposed a pale unhealthy spreading ulcer, bleeding on the slightest touch, of a depth proportionate to the duration of the scab, with livid swollen borders, and in old per- sons often very difficult to heal and even when healed leaving a dark-coloured cicatrix. Diagnosis.—Rupia may be confounded with pemphigus, ecthyma, and venereal pustular erup- tion, but the bulla? of pemphigus are large, full, and very prominent, and generally contain a serous fluid, while the bulla? of rupia are small, flattened, quickly become flaccid, and contain a fluid, which, if not sanious or purulent from the commence- ment, very quickly becomes so. Gangrenous pem- phigus pours out a sanious fluid, but does not form scales like rupia. The ulcerations of rupi- are deep and indented, while those of pemphigus are superficial, resembling excoriations. The shape of the scab in rupia prominens at once dis- tinguishes this variety from pemphigus. Rupia is frequently found in conjunction with ecthyma undum and cachecticum, and Plumbe has classed rupia and ecthyma together. The two disease* RUPIA —SCABIES. 59 are, however, very distinct in their pathology and appearance. Ecthyma commences as a pustule, rupia as a bulla. The scab of rupia is generally easily removed; the scab of ecthyma is strongly adherent. Around the circumference of the scab of ecthyma there is deep-seated inflammatory hard- ness, extending into the subcutaneous cellular tissue; around the scab of rupia there is only a superficial red areola, the cuticle over which can be traced in continuation with the surface of the scab. The scab formed on some of the pustular venereal eruptions bears a very close resemblance to the scab of rupia; and as both diseases are likely to occur in the same broken-down constitu- tions, there is risk of confounding them. The venereal scab and pustule are, however, found to proceed from pustules with hardened bases, not from bullse as in rupia, and they are generally surrounded with the peculiar syphilitic copper- coloured areola?. These characters, with the pre- sence of some of the usual constitutional symp- toms of syphilis, will suffice to distinguish the two diseases. Plumbe speaks of having seen evil re- sult from mercury being administered for rupia, under the mistaken supposition of its being a venereal affection. Few practitioners, however, in the present day, after the clear and lucid views laid down for the treatment of venereal affections by Mr. Carmichael, (an Essay on Venereal Dis- eases, and the Use and Abuse of Mercury in their Treatment, by Richard Carmichael, M. R. I. A., &c), would push mercury to any extent for such appearances, even admitting them to be of vene- real origin. Prognosis. — The duration of rupia is very uncertain, running through its course in a few days, or extending to months. The disease is severe in proportion to the age of the patient, or weakness of the constitution. The slowly-healing ulcerations often keep up a low fever in the sys- tem, and thus injure the health, but rupia is scarcely if ever a fatal disease. Causes.—Rupia may be considered as altoge- ther a constitutional affection, being only seen in the aged, or in the debilitated from any cause, but particularly from intemperance, abuse of mercury, or want. Acute diseases affecting the skin, and leaving much debility after them, predispose to it; thus it appears as a sequela of small-pox and scarlatina. The scrofulous are peculiarly subject to it, and it is most prevalent during the winter season among the poor who are badly fed and clothed. Treatment.—From what has been just stated relative to the causes of rupia, its treatment is easily anticipated. The remedies are a light nu- tritious diet, cleanliness, the warm bath, attention to the state of the bowels, and sarsapatilla or cin- chona, with the mineral acids. Dr. A. T. Thom- son, in his edition of Bateman, says that slight mercurial courses carried so far as to affect the mouth are sometimes necessary. Mercury, when used in this disease, should according to the best observers be used only as an alterative, and in its mildest forms, as in Plummer's pill. As to local applications, the scabs should be removed by a poultice, and the raw surfaces, if painful, are to be stuped with decoction of bran and poppy- heads. Relaxing or emollient applications, how- ever, should be used only for a shut time : the surfaces of the ulcers very soon require stimulat- ing applications, and the strength of these must vary, according to the relaxed state of the ulcers, from a weak solution of nitrate of silver to the application of the solid nitrate, the strong nitric or muriatic acid, or ointment of red precipitate of mercury. Rayer recommends the ulcers to be dressed with saturine cerate, pledgets of lint to be placed over this dressing, and all to be confined with a bandage which shall keep up a moderate compression. He recommends the ulcers when indolent to be dusted with powdered supertartrate of potass, or a solution of it to be used as a lotion. In this, as in all skin diseases where there is ul- ceration attended with low irritative fever, internal opiates given at bed-time to procure sleep form an essential requisite in the treatment. D. J. CORRIGAN. [SALIVATION, See Ptialism.] SCABIES.—This is the classical word now universally used to designate the well-known con- tagious vesicular disease of the skin, called popu- larly, in English, itch, French, gale, German, Kratze, Italian, rogna, &c. These vulgar appel- lations, except the French, (the etymology of which is doubtful,) are derived from the property which our English expresses, the intense itching and irresistible scratching which it excites. Sca- bies is the word by which the Latins rendered tho ipwpa of the Greeks, a term under which the Iattei comprehended a number of papular and squamous affections, although they at length appropriated i< to the disease which we now denominate psoriasis The confusion which for a long time attached to ■dywpo necessarily involved its synonym scabies, and prevented it from becoming definite in iu signification, until they were divorced by Celsus, who restricted the Greek term to scaly diseases, and excluded these from the comprehension of the Latin scabies. The Roman physician and his successors did not, however, confine its significa- tion within its present limits, but included under it other pustular and pruriginous affections, and so caused an inaccurate latitude in its acceptation, which prevailed to a comparatively recent period. The advance of cutaneous pathology at length isolated the disease, but the verbal confusion was revived by Cullen and others, who, when scabies had been definitely fixed, chose for the designation of the itch the term anciently used in so indefinite a sertse by the Greeks, psora, which (with a pro- longed termination) Willan, with a greater regard to 'ts old signification, appropriated to the scaly disease. No imputation of inexactness in this instance attaches to the old medical writers, for words must ever be varying and inconstant in their signification until the state of science per- mits the diseases which they represent to be investigated upon enlightened principles, and dis- criminated by a true nosology; but authors are to blame, who, after this period arrives, embarrass the received nomenclature by arbitrarily multiply- ing names, or changing them from their general acceptation. Scabies is one of the cutaneous diseases the distinct identity of which is best confirmed by pe culiar characters, yet in the description of whic!; 60 SCABIES. such a variety exists as to render it extremely difficult to give a comprehensive account of its history and symptoms. An artificial arrangement would be very desirable for this purpose, but in seeking for such we find how difficult it is to fix arbitrary bounds within which natural phenomena may be circumscribed. «This troublesome dis- ease," says Bateman, « from its affinity with three orders of eruptive appearances, pustules, vesicles, and papula?, almost bids defiance to any attempt to reduce it to an artificial classification." (Sy- nopsis, 7th edition, 1829, p. 278.) A ready illus- tration of this statement is found in the fact that while Willan has placed it in his order " pustula?," Biett and Rayer, who have adopted his system, classify it among the vesicles; and again, Dr. Paget, the author of a late ingenious essay on the classification of cutaneous diseases, (Edin. Med. and Surg. Journal, vol. xxxiv. p. 270,) coincides with others who consider it as appertaining to the papula?. It does not belong to our object to main- tain the credit of the artificial arrangement, but we may remark that this discrepancy, which shows its defectiveness in this particular as a system, by no means detracts from its practical advantages; on the contrary, the purposes of study and description demand more urgently the aid of arbitrary methods of arrangement when the natural appearances are diversified. It is admitted by the majority of observers, that by far the greatest part of the eruption of scabies is composed of vesicles, so that we unhesitatingly agree with the French authors above cited in regarding its type as essentially vesicular. The transparent apex of the elevation is often so minute or so fugitive as to give the idea of a papula, if not observed attentively and at the seasonable period of its course. With respect to the true papula?, which are often interspersed amongst the vesicles, it is to be observed that in all eruptions of the skin (whether their real type be vesicle or pustule) there is a period at which the elevation is merely a papula, and it frequently happens that in a vesicular or pustular eruption some pimples proceed no farther in their develop- ment than the state of papula?. Nothing is more common than to see among the pustules of porrigo several which have no purulent apex, having never advanced beyond the papular stage ; but on this account their genuine character is not the less established, being properly regarded as undeve- loped pustules. The papula? which complicate the vesicles of scabies bear a larger proportion to the true type than in the example of porrigo, but they appear to possess a similar relation to it, being as it were abortive vesicles. The occurrence of pus- tules in scabies forms, indeed, a more decided va- riety, as one species of it seems to be truly pustular in its nature. Vet it is not to be overlooked that some of these apparent pustules are also primi- tively vesicles, in which an inflammation of more than ordinary acuteness has produced a purulent secretion instead of transparent serum. Accord- ing, then, to the opinion here stated, we embrace the vesicular as the true type of the eruption, and >cgard the deviations of papula?, and in part those of pustules, as caused by casual variations in the Intensity of the inflammatory action. On the one hand, papula? occur where the inflammation stops short of maturing vesicles; and on he other pustules are met with when, proceeding to an immoderate degree, it fills the vesicles with pus in P,aThe0crntUagi'ous nature of this eruptive disease is the most essential character of its history. Its vesicles are minute and slightly acuminated with a pearly semi-transparency at their summit. They may arise at any part of the body, and spread until it cover every part except the face, which appears to possess a singular immunity from their invasion. The hands and arms are always prin- cipally affected, and are often so when no other part of the body partakes of the eruption, which is sufficiently accounted for by the fact that infec- tious contact usually occurs in this situation. The vesicles are mostly distinct, but have a dis- position to accumulate at the flexures of the joints; being almost invariably found confluent on the soft fold of skin between the fingers and at the joint of the phalanges and wrist, and often at the larger articulations, if the eruption be more exten- sively spread. The intense itching which is the characteristic feature of this troublesome disease accompanies the first appearance of the eruption, and, indeed, seems generally to precede it, as the inflammatory elevation which generates the vesicle is much promoted by the scratching, which the pruritus irresistibly induces. It increases from the commencement until each vesicle attains a certain degree of maturation, when it decreases. The annoyance which it produces is in proportion to the extent of the eruption; if the vesicles be few in number, are developed slowly, and confined to a circumscribed locality, it may cause little atten- tion ; but when they are numerous and extensive, and come out with rapidity, the pruritus rises to an intolerable height, and produces inexpressible irritation. The patient then seeks to assuage if by scratching, from which, howsoever he may he cautioned against it, he feels it impossible to refrain. Temporary relief may be obtained from this by changing the itching sensation into the pain of laceration, but he only lays up in store a future visitation of greater intensity. The action of the nails increases the inflammation, which causes new crops of vesicles to spring up, and aggravates the pruritus in the old. More or less of the same consequences flow from any other cir- cumstances which give rise to even a transitory excitement of the cutaneous circulation, as the warmth of bed, the digestion of a stimulating meal, or the use of spirituous potations. Several days elapse between the time of infec- tious contact and the manifestation of the pruritus, which period is called in this as in other eruptive diseases the incubation. Its length is much mo- dined by the age of the individual, as connected with the susceptibility of the cutaneous surface to impressions. In childhood, when the skin is soft and active in its functions, the incubation has generally three or four days' duration ; in adults t averages ten to fifteen, and in old age, when Derin^ 1S ?nld ""* haS lost its vascularity, this Period is still more prolonged. I„ the ius nScT' m Wuid, thCuSkin'S function is lesS ?aTn m-the 1yn,Phatlc ™d sanguine.it of c lCrPrtlVdy Protracted- The relations oi climate and seasons, moreover, have a sensible SCABIES. 61 effect on it, cold and heat respectively retarding and accelerating the first appearance of the dis- ease. The existence of an inflammatory affection of any internal organ is another condition which appears to diminish the susceptibility of the skin to its infection, and to add to the period of incuba- tion. The circumstances connected with this latent period are worthy of attention, not only on account of their intrinsic interest as pathological facts, but because they afford an important prac- tical deduction, which is as follows : the duration of this period has a relation to the actual course of the disease, and the facility with which it may be removed ; when the eruption appears promptly after infection has been contracted, it may be in- ferred that the disease can be Speedily conquered by the appropriate remedial applications; but if, on the contrary, the skin has exhibited a tardy inactivity in producing the eruption, when fully developed, the latter will be proportionately in- veterate and less amenable to therapeutic means. When scabies has fully appeared, although it may be modified as to its intensity by circum- stances, it always assumes a progressive course, until arrested by treatment; it has no tendency like the exanthematous eruptions to a spontaneous cure. From its original seat it spreads until the whole surface is affected, but collects especially where the skin is disposed in loose folds, subject to friction, as the axilla, the internal parts of the thighs, and fold of the buttock, as well as the flexures of the articulations. The situation where it may first show itself appears to be entirely de- pendent on the liability of different parts to con- tact with infected persons. This is demonstrable from the consideration of it in different individuals, whose condition in life exposes one part of the body more than the rest: for example, in tailors, sempstresses, and shoemakers, it commences on the hands; in infants in the nurses' arms, the nates are frequently found to be the part first af- fected ; and if, on the contrary, the nurse receive it from the child, it breaks out on the hands, and sometimes (which is more in point) on the breast. An exception to this rule would seem to exist in the case of dyers, smiths, and sawyers, whose hands and wrists are rarely primitively affected, and often escape, while it infests other parts: this is to be ascribed to the rough hardened state which the hands of these tradesmen contract from labour, and doubtless in the first two their im- munity must be in some part owing to the chemi- cal agents with which their employments bring their hands in contact. Sulphuric acid and other powerful astringents form a main ingredient in the dyers' liquors, and the iron and embers of the forge constantly impregnate the smiths' hands with sulphureous vapours, which are at once its best prophylactic and cure. Redi asserts that he knew an instance in which the face became the first part affected, from the contact of the collar of an infected mantle; but its appearance on the face at all is so contrary to experience deduced from innumerable observations, that this has been denied to be a genuine case of scabies by later writers. Willan and Bateman divided scabies into four species, derived purely from the variety of form which the disease assumes. They have no» been followed in this by the recent authors who have borrowed their arrangement. As the framer of a system, Willan was disposed to attach too much nosological importance to his divisions, and his followers conceiving that they; imply theo- retic error, have in many instances relinquished them. It does not appear, however, that by so doing they have attained either to more simplicity of arrangement or fidelity of description, but rather the contrary. In our opinion, the specific distinc- tions which Willan employed are as valuable as the grander divisions of his system, and to those who are jealous about natural arrangement they are less objectionable, as being the mere expres- sions of facts, which may be received without re- ference to any theory of classification. Artificial subdivisions of cutaneous diseases founded on real differences in external characters, if they have no other advantages, greatly facilitate their study, and without the aid derived from this source their description becomes necessarily either vague or defective. In scabies, these practical means of discrimination are particularly requisite, as its di- agnosis, which is of great importance, is chiefly to be arrived at (where contagion cannot be proved) by an accurate knowledge of its external characters. We now proceed further with its description, and in addition to the general remarks with which we commenced it, we recommend attention to the following divisions, which are the same as those proposed by Willan. Far from being the mere offspring of theory, they were suggested to him by their common use amongst the lower order, whose familiarity with it forces them to be intimately ac- quainted with the various forms in which it ap- pears. Of these they distinguish four, designated the rank, watery, pocky, and scorbutic itch, which Willan adapted to his nomenclature under the fol- lowing titles, viz.:— Scabies papuliformis. ------lymphatica. ------purulenta. ------cachectica. Scabies Papuliformis, or Rank Itch.'—In this form of scabies the eruption is generally ex- tensive, and accompanied with slight inflammation in the vesicles, and intense itching. It is found chiefly to infest the fingers and wrists, but also spreads extensively upon the trunk, particularly the front part of the chest and abdomen. The elevations resemble papula?, and thus seem to. evince an affinity between this form and prurigo and some varieties of lichen; but where they are fully developed and unbroken by scratching, a close inspection may always detect the transparent apex which indicates its vesicular character. The itching is so troublesome that frequent scratching is resorted to, and the abrasion of the vesicles and even of the skin which ensues, changes the primi- tive appearance of the eruption ; " long red lines are here and there left, and the blood and humour concrete upon the vesicles into little brown or blackish scabs." When it occurs in a sanguine habit, or if it be inordinately exasperated by scratching or other circumstances, some scattered pustules sometimes make their appearance, filled with thick yellow purulent matter. Scabies Lymphatica, or Watery Itch.— The difference between this and the former is ir- 6J SCAB considerable. The separate vesicles are larger and do not partake of the papular character, being full of serum to the base, which besides exhibits no inflammatory redness. The pruritus is extremely troublesome, and when the vesicles are ruptured, moist excoriations are apt to form, upon which after a certain time dark scabs concrete. The most ordinary appearance which this variety pre- sents is a compound of the three stages just re- ferred to, viz. the entire vesicle, the excoriation succeeding its laceration, and the scab which co- vers this ulcerated part when it begins to heal. It seldom extends like the former variety to the trunk, but is chiefly found collected at the lower parts of the extremities, on the fingers, wrists, back of the hands, and on the feet and toes. Scabies Purnlenta, or Pocky Itch.—This possesses more the characters of a distinct species than any of the other forms, and evinces the ne- cessity of marking these varieties. As Bateman well remarks, "it is often mistaken by those who con- fine their notion of scabies to the ichorous vesicles of the varieties already noticed." Heberden had divided the disease into two species, comprehend- ing in the first two former varieties under the name of " pustula? exigua?, aqua plena?." (Com- ment, de Morb. Histor. et Curat. Frankf. ad Moen. 1804. P. 102.) The other he describes as » ma- juscula? cum fundamento rubro, et pure implean- tur, fere tanquam variola?." This resemblance of the round pustules which constitute this species to small-pox, caused the vulgar to denominate it pocky itch. They arise distinct, upon an inflamed base, above which they are considerably elevated: after a few days they maturate and break, having attained frequently to a diameter of two or three lines. The pruritus which they occasion is mixed with a painful tension of the part, different from that which occurs in the vesicular forms. After their breaking they leave a cracked ulceration be- hind, the heat and stiffness of which cause con- siderable pain. The pustules may spread like the vesicular form over the body, but seldom extend far from their original seat, which is usually the hands or feet. In these situations they are largest, and two or three of them sometimes coalesce be- tween the knuckles, especially between the index finger and thumb. The scabby concretions which at length form upon the ulcerations adhere for a considerable time during the healing process. The pustular scabies occurs usually in children • before the age of ten years. Scabies Cachectica, or Scorbutic Itch.__ This is not distinguished from the forementioned varieties by difference in external character ; for it appears under the forms of the other varieties at one time indiscriminately mixed, at another ex- hibiting them separately in different parts of the body. It mostly occurs in persons of debilitated constitution, brought on by indigence and intem- perance, and is the most intractable form of scabies. It is not unfrequently combined in such individuals with other cutaneous maladies as lichen, prurigo, ecthyma, and impetigo ; and Bate- man asserts that when the latter disease is super- added, it, as well as the scabies, possess a conta- gious character. He also remarks that the most severe degree of it which his experience made mm acquainted with, exhibited itself in persons IES. who came from India, and he had often observed it in children brought from that country It . • *„.i <> rniiTHD. a term winou is there denominated " courap, <» ,..-., .. mere uen i wmch Bontlus ?£t^t£ZZ. lib. iii- cap. 17) describes under the name of herpes, sou impel go Indica, and Sauvages under that of scabies Indica. It was, perhaps, superfluous to make a separate spvcies of this, inasmuch as it possesses no par- ticular form which distinguishes it from the others; yet, as it is so disposed in Willan s divisions, it "might be invidious in such a matter to use an arbitrary power in altering an established arrange ment, which we have taken advantage of fc greater facility of description. In whatsoever form scabies manifests itself, it is to be regarded entirely as a local affection, being never like other vesicular eruptions connected with disorder of the internal organs. It gives rise to no disturbance of the circulation, except in severe cases of the pustular scabies, which, from the inflammation sometimes attending it, causes slight febrile action in children. Some authors recount a list of the most formidable diseases as liable to be produced by its retrocession and the metastatic transport of the cutaneous irritation to the vital organs. These notions, however, are now disregarded, being justly considered as the imaginary fabrications of an exploded theory, which pretended that a specific virus residing in the serum of the blood was the cause of scabies. We conceive that the observations of others which assert that important diseases of the internal or- gans have been cured by its eruption are to be equally unheeded. Unprejudiced experience de- monstrates that it exerts little or no pathological sympathy upon the internal organs, and therefore such cases as those narrated by Beer* and others can be only regarded as coincidences. The disease chiefly shows itself amongst chil- dren ; yet on this account it is not to be inferred that it shows a preference for youth more than age. This is to be attributed solely to the fad, that children are more brought in contact with in- fection than adults, from their heedlessness of ex- posure and inattention to cleanliness. It depends upon the same cause that amongst the working classes males are more generally affected with it than females. Climate does not appear to have much effect in modifying its prevalence,—although it is certainly more common in the northern parts of Europe than the southern, an observation which we think must be connected with the fact that in- dividuals of sanguine and lymphatic are much more liable to it than those of bilious tempera- ments. Habits of uncleanliness, however, are more powerful than this predisposition arising from the temperaments, of which its great preva- lence amongst the Polish Jews and Spaniards affords examples ; for amongst these people, as is well known, the bilious preponderates beyond comparison oyer the opposite temperaments. It prevails in so general and constant a mannei in some countries that it may be said to be en- demic. In Poland and Hungary the mass of the *Geschichte eines geheilten vollkomrnenen von »■ uckgetretener Kratze entstandenem. SrhwSwn ™ai" [Account of an Amaurosis caused bv r . • „ Itch, which was perfectly cured) 8v° Vi "^2 ; u- Vienna, 1798. SCABIES. 63 population are constantly more or less infected, and it is equally rife in Galicia and Asturias in Spain, in Lower Brittany in France, and in cer- tain parts of the Highlands of Scotland. It is, however, no stranger amongst the indigent classes of every country, and where it is found to infest one region with peculiar pertinacity, this is not to be attributed to any special influence of the atmo- sphere or the soil, which alone would properly entitle it to be called endemic, but to the habits of the poor population. It has been suggested that salt diet and the neighbourhood of the sea were concerned in maintaining it in some districts, but these circumstances have no influence in pro- ducing it, although they are frequent concomi- tants of that which is its true promoting cause,— inattention to cleanliness of the person, and par- ticularly of the habiliments. Change of linen is the surest protection from it in a family or in a country, and we may with certainty predict its prevalence amongst every people where custom or necessity has precluded this best preservative of the health of the skin. This malady inspires, as might be supposed, no friendly feeling in communities, and it is cu- rious in this respect to remark the difference be- tween it and those contagious eruptions which put life in jeopardy, as small-pox, measles, &c. With whatsoever dread the latter may be contem- plated, they do not produce disgust; but the itch, being free from danger, may be treated more dis- respectfully, and is very generally regarded as contemptible. However, different nations have different opinions on this subject; it is reported of the inhabitants of the Spanish provinces before mentioned, that they retain it often from the cradle to the tomb, and that they are not only careless of its concealment, but regard it as a kind of hereditary possession ; they even refuse to use means to be freed from it, alleging that they are not willing to change the customs of their ances- tors. (Diet, des Sciences Med. t. xvii. p. 183.) But in countries where civilization is more dif- fused, its residence is less tolerated. Here even the imputation of the itch becomes almost inju- rious, and sometimes engages philosophers in its refutation, of which the following is an example. " Laennec was a true Breton, fond of his country and jealous of its honour. It is amusing to ob- serve the high tone he assumes in refuting a charge brought by a certain writer against his native country, for being infamous for an epidemic itch. He solemnly assures us, that if in very truth «la gale s'observe quelquefois en Bretagne, on en doit moins accuser les localites, que le passage et le sejour des matelots." (Forbes's Translation of Laennec, Author's Life, p. xxviii.) Equally patriotic renunciations of it have been made in our own islands. Diagnosis. — There is scarcely any disease compromising the general health in so trivial a degree in which it may be more important to the reputation of the practitioner to be able to deliver a categorical diagnosis than in scabies. He is in fact frequently consulted for no other purpose than to decide whether an individual has not brought this contagious affection into his circle ; and as the physician's opinion on the one hand sets him free from this suspicion, and on the other sentences him to a temporary banishment from society or even from his employment, it is obvious how much it behoves him to be able to distinguish it without error. In forming his opinion, he should learn to be as much as possible independ- ent of the criterion furnished by its contagious quality, for it will be generally where this point is yet undecided that his judgment will be sought for. When some evidence of exposure to infec- tion exists in addition to the proper characters of the eruption, there is no difficulty; but if such be unattainable, it will often require all the re- sources which an accurate acquaintance with it and other affections which resemble it supplies to distinguish between them. The eruptions with which it is liable to be confounded are some forms of lichen, prurigo, and eczema. The papular ele- vations of lichen are attended with considerable itching, and are frequently abraded by scratching, so that considerable resemblance may exist be- tween them and scabies, particularly the first va- riety of it above noted, (s. papuliformis.) If the latter be present, the apparent papula?, ex- amined in an unbroken state, will be found to be topped by a vesicular apex, and where they have broken spontaneously, a dark scab remains; but in lichen the papula is solid, even to the summit, and it passes away in a scurfy exfoliation. Lichen occupies the back of the hand, and the external surface of the limbs, and is seldom or never de- veloped in the intervals of the fingers. Moreover the itching is not nearly so intense as in scabies, and is of a more remitting nature, and the papu lar eruption is commonly attended by some con- stitutional disturbance which is foreign to scabies. In the lichen urticatus the eruption is of a more acute nature, and has occasionally a few vesicles interspersed amongst the papula?, which might confound an observer who relied on any single characteristic; but the diagnosis in this case is still easier than in the simple lichen—the inflamed wheel-like papula?, causing rather a deep tingling than an intense itching, sufficiently distinguish this eruption. Finally, the suspicion of contagion will seldom attach to any form of lichen. The itching of prurigo is of a still more vehe- ment character than that of scabies; they were of old frequently confounded, insomuch that the former was sometimes erroneously denominated scabies sicca. (See Prurigo.) The diagnosis between them is not difficult if these points be held in memory. Prurigo occurs chiefly in elderly individuals; its papula? are flat, and when abraded by the nails no serous fluid is effused, but a dark spot of blood concretes upon their surface. The situation also of the pruriginous eruption (as that of lichen) is distinguished from scabies by its preference to the surfaces of extension on the ex- tremities, instead of those of flexion, which the latter particularly affects. Prurigo, moreover, is not contagious. In eczema we have a vesicular eruption, which often bears a striking resemblance to scabies in the second variety, (s. Iqmphalica.) Its vesicles,. however, are more flattened and confluent thar> those of scabies, which are acuminated and dis- tinct. But when the disease is passed to an ul cerated and scabby state, such distinguishing characters may be wanting, and then other cr w SCABIES. euinstances must be sought out. Eczema is for the most part a local affection, and when the itch has in any place assumed the ulcerations and soft scabs which resemble it, the eruption has pro- ceeded to a considerable extent, and will doubtless shovv its proper form in the parts which it has most recently invaded. The irritation of eczema is a stinging or tingling sensation very different from the pruritus of the itch, and its origin may be often traced to the action of irritating causes upon the skin, as sugar, lime, and other acrid substances, or to exposure to the solar rays or great heals. Very lately a female presented herself to the writer with an eruption at the root of the right middle finger, which from its situation and ap- pearance was difficult to distinguish from scabies. She ascribed its origin tw milking cows, whose teats were in a diseased state. The pruritus was not that of scabies, and after a careful examina- tion it was concluded to be a vesicular form of impetigo. Bateman calls attention to the possi- bility of confounding the pustular form of scabies with impetigo, and even with ecthyma ; and al- though this seems remote, it is yet only a prudent caution to keep in mind every form of cutaneous disease which bears any affinity to it. A circumstance in the history of scabies of the greatest moment, is the simultaneous presence of the diseases which we have just contrasted with it for the sake of diagnosis. This is indeed rare in ordinary cases of itch, but the fact of its occa- sional occurrence forcibly impresses the necessity of cautious examination, and adds much practical importance to the diagnosis, because those com- plications require a line of treatment quite dis- tinct from that of scabies. They are met with in the cases in which much inflammation has at- tended the scabid eruption, and (which serves to illustrate what we have said as to their different treatment) they are very frequently produced by improper applications for its cure, such as power- fully irritant lotions or frictions. The actual complication which may be present will be much influenced by the constitution and age of the subject; in young and vigorous habits, the excess of irritation will mostly take the form of eczema or of impetigo, while in those of an opposite condition pustules of ecthyma may appear, or the inflammation may seize on the cellular tissue, and an eruption of boils be the consequence. Caze- nave and Schedel remark that the same subject may present at once " vesicles of itch, pustules of impetigo, pustules of ecthyma, and boils," (Abrege Pratique des Mai. de la Peau, Paris, 1828, p. 120,) a case which would exercise the diagnostic tact of the physician to discover the primary contagious disease amongst so many complications. Causes.—The universally diffused cause of sca- bies is contagion, and it appears to be the disease which of all is most readily communicated by contact. When it once gains admission into a family, the greatest caution often fails in prevent- ing it from infecting every individual. A question exists undecided among pathologists as to whether :t ever originates from any other source than con- tagion. It was observed by Sir John Pringle, that m military hospitals the patients often became the subject of itch after the crisis of fevers, (B..teman's suojec . Ooo nf),p