during the night, at which time the pains become most GEN. XII. severe; and are then chiefly disposed to shift from one joint to another. SPEC. I. a A. acuta artuum. Articular rheumatism. retics. Where fever is violent, and especially where the frame is robust, our only effectual remedies are copious bleed- Remedial ing and the use of diaphoretics; by the former, which Process Copious will often demand repetition, we take off the inflamma- bleeding, tory diathesis, and by the latter we follow up the indication which nature herself seems to point out, and endeavour, by still farther relaxing the extremities of the capillaries, to render that effectual, which, without such collateral assistance, is, as already observed, for the most part exerted in vain, and an unprofitable expenditure of strength. The most useful diaphoretic we are acquainted and diaphowith is Dover's powder; and its benefit will often be increased if employed in union with the acetated ammonia, and sometimes if combined with camphor. Ape- Apele rients are useful to a certain extent, but they have not serviceable. been found so serviceable as in various other inflammations. Small doses of calomel have occasionally, however, seemed to shorten the term of the disease, though they have not much influence in diminishing the pain. To obtain this, Dr. Hamilton has combined calomel with opium; and in his hands it appears to have been successful. Opium alone is rather injurious; nor has any Opium alone decided benefit resulted from other narcotics, as hyoscy-seld amus, hemlock, and aconite. They are recommended by several writers, but I have seen them tried both in small and large quantities without effect. Aperients seldom use ful. We have observed that there is no constitution invul- Venesection sometimes nerable to the attack of rheumatism, although the young injudicious; and the vigorous fall most frequently a prey to its torture. Hence not unfrequently we meet with it in persons of weak and irritable habits, who will not bear the lancet with that freedom which gives any chance of its and local being useful. Local bleeding is here to be preferred; not to be but it cannot be depended upon: since, though the pain depended may diminish, or even totally subside, it is, in many cases, only to make its appearance in some other quar bleeding upon. SPEC. I. GEN. XII. ter. Here, also, if in any case, we have reason to expect benefit from uniting stimulants with diaphoretics, as ammonia, camphor, and the resinous gums and balsams. a A. acuta artuum. Articular rheumatism. Rhododendron, In such habits, and particularly if opium should disagree with the system, it may be worth while to try the rhododendron (r. Chrysanthum Linn.). This plant is a native of the snowy summits of the Alps and mountains of Siberia; and in Russia, as we learn from Dr. Guthrie, is employed very generally both in gout and rheumatism with a full assurance of success, a cure seldom failing to be effected after three or four doses*: in consequence of which, it has formed an article in the Materia Medica of the Russian Pharmacopoeia for nearly a century. often useful; Dr. Home tried it upon a pretty extensive scale in the Edinburgh Infirmary, and found that it acts both as a powerful diaphoretic and narcotic; and is at the same time one of the most effective sedatives in the vegetable kingdom. In most of the cases it retarded the pulse very considerably, and in one instance reduced it to thirty-eight strokes in a minute. It has also the advantage of occasionally proving aperient. But it sometimes produces vertigo and nausea; and as a general medicine is not to be preferred to Dover's powder †, or even the antimonial powder with opium, where the latter can be borne without inconvenience. but not to be preferred to Dover's powder. Free use of bark in debilitated habits; often advised indis It is possibly also in habits of this irritable kind, if in any, that we are to look for that extraordinary and decisive benefit from a free use of the bark at an early period of the disease, which we are told has accompanied it by authorities which we cannot dispute. Contemplated as criminately. a highly acute inflammatory affection, nothing could at first sight appear to be more inconsistent with all rational practice than the use of such a medicine, and every one must feel predisposed to coincide with Dr. Cullen, when he tells us, in reference to acute rheumatism, "I hold • Med. Comment. Vol. v. p. 434. + Clinical Experiments, Histories of Dissections, 8vo. Edin. 1780. SPEC. I. a A. acuta Articular rheumatism. Diversity of high authoopinions of rity. Of Cullen. Of Morton. Fothergill. the bark to be absolutely improper, and have found it to GEN. XII. be manifestly hurtful, especially in its beginning, and in its truly inflammatory state."* Yet in direct opposition artuum. to such feelings and such assertion, confirmed by numberless testimonies of equal weight, we find the bark freely prescribed from the onset of acute rheumatism, apparently with success, by Dr. Morton, who seems first to have employed and recommended it for this purpose, down to our own day, through a stream of the most celebrated physicians, as Sir Edward Hulse, Dr. Hugh Hulse. Smith, Dr. Fothergill, Dr. George Fordyce, and Dr. Fordyce. Haygarth of Chester. Dr. Fordyce affirms distinctly that, at the time of writing, he had for fifteen years relinquished bleeding in favour of the bark; and that during this period of time he had not above two or three patients out of several hundreds for whom he had prescribed it; and had rarely met with any instance of a metastasis, a very common occurrence when he was in the habit of employing copious bleeding +. Dr. Swediaur has added Swediaur. his testimony to the same effect. He was first taught the value of the bark in this disease by his friend Dr. H. Smith, and strenuously adhered to its use, from perceiving its benefit, afterwards ‡. The success of Dr. Haygarth is not less striking and Haygarth. extraordinary and the history of it is given with an air of candour that entitles it to full attention. Dr. Haygarth's residence was at Chester; and his tract lays before us, the result of an extensive practice in rheumatic diseases, in that city and its neighbourhood, during a period of thirty-eight years. His cases amount to four hundred and seventy; and of these, one hundred and seventy, or something more than a third of the entire number, appear to have been cases of acute rheumatism, or rheumatism in conjunction with fever, the rest being of a chronic kind. In the acute cases, by far the greater number of patients had the joints alone principally * Mat. Med. Part 11. Ch. 1. p. 100. VOL. II. R R + On Fever, Dissert. III. SPEC. I. a A. acuta artuum. Articular rheumatism. GEN. XII. affected, a few the muscles alone, and the rest both the muscles and the joints. The average of the pulse in the above hundred and seventy cases, was a hundred strokes in a minute, and the blood always exhibited the inflammatory crust when drawn. Other remedies were tried, but the bark was by far the most successful. In four cases only out of a hundred and twenty-one, it is allowed to have failed; so that we cannot be much surprised at Dr. Haygarth's conclusion that the bark does not cure an ague so certainly and so quickly as it does the acute rheumatism*. Attempt to reconcile How are we to reconcile such conflicting results, and harmonize the authorities now adverted to? I have also flicting tes- tried the bark in various instances from an early period these con timonies. Local varie of the disease, and when the bowels were free from confinement, but I have rarely met with success: and have often, like Dr. Cullen, had reason to think it injurious. Is it that in certain habits, as those of great weakness and irritability; in certain districts, as in low and swampy grounds, charged with the fomites of intermittents; or, in certain temperaments of the atmosphere, as in sudden successions of wet and sultry weather, the bark has a tendency even in acute rheumatism, as we know it has in spasmodic affections occurring in weakly constitutions, to take off tension and rigidity as well as to take off relaxation; and thus to induce a healthy tone by letting down the action of muscular fibres, when necessary, as well as raising it when necessary also? This view of the subject may account for its beneficial effects in many of the above cases, but will not explain the general and indiscriminate success which seems to have attended it: and hence, there is still a something behind, some unknown principle or contingency, which yet requires to be brought forward before we can reconcile these "factis contraria facta." The above remarks will apply to the other varieties of ties of acute acute rheumatism as well as to the first, that which rheumatism. * Clinical History of Diseases, 1805. SPEC. I. a A. acuta affects the joints generally, and is the most common form GEN. XII. under which the disease shows itself; yet the few following observations more immediately directed to the other artuum. varieties may not be altogether unprofitable. Articular rheumatism. lumborum. Lumbago. LUMBAGO has sometimes been confounded with ne- A. acuta phritis, or a calculus in the kidneys or ureters; but the proper nephritic affections are distinguished by some irregularity in the secretion of urine, and, as we have already had occasion to observe, with a numbness shooting down the thigh, and a retraction of either testicle. RHEUMATISM OF THE HIP-JOINT was called among y A. acuta the Latins ischias, from ioxíos, the Greek term for hip; which was afterwards corrupted into isciatica or sciatica, a word that has occasionally found its way into the dramatic poetry of our own country, as in Shakespeare's Timon, -The cold sCIATICA Cripple our senators that their limbs may halt As lamely as their manners. This variety, at its onset, has sometimes been mistaken for a phlegmonous inflammation of the psoas muscle. But in the latter there is, from the first, less tenderness to the touch, but much more enlargement, and the pain shoots higher into the loins. In sciatica, indeed, the whole limb, instead of continuing to swell, soon wastes away, and the emaciation extends to the nates of the affected side, so that the muscles have neither strength nor substance; while the thigh becomes elongated from the fibrous relaxation that takes place. coxendicis. Sciatica. When ACUTE RHEUMATISM attacks the PLEURA, or any A. acuta of its duplicatures or appendages, it exhibits many of the thoracis. Spurious symptoms of pleurisy or peripneumony. But here, also, pleurisy. as in every other case of rheumatism, we have much greater tenderness upon pressure than in phlogotic inflammation, while the pyrectic symptoms are considerably less, and often highly disproportionate to the pain that is endured, so that the degree of pain and that of fever become no measure for each other. There is this peculiar character belonging to the three |