membrane, quite independently of inflamma- | distinguished. In many instances, also, the in⚫ion.*

The diseases described by Mr. Chevalier and Dr. Graves, seem to the editor to correspond to the enormous growth of the scrotum, so com. mon in Egypt and other warm countries, yet sometimes met with in France, this country, and other parts of Europe.t Dr. Graves is of opinion, that the example which he has published is entirely different both from phlegmasia dolens and the Barbadoes leg, which affections, he says, arise from inflammation. It certainly appears, that some extraordinary enlargements of the lower extremity have depended upon a chronic growth and thickening of the integuments and cellular tissue, no inflammation having occurred, at all events, until the disease was far advanced. Yet, in other instances, a similar alteration of the skin and cellular membrane has been preceded either by an attack like that of phlegmasia dolens, as happened in Mr. Chevalier's example, or by fever, and heat and redness of the skin, as illustrated in one curious modification of the disease, described by Dr. Graves, and, as it seems, by no means uncommon in Ireland, where it affects the arms, perhaps, more frequently than the legs.]

In the tumid leg of hot climates, the skin, instead of maintaining the paleness of the first species, very soon becomes suffused with a deep red or purple hue; while the saburral fluid that exudes from the cutaneous exhalants, concretes, as its finer parts fly off, into rough and sordid scales, and the skin itself becomes enormously thickened and coriaceous.

The effusion is usually preceded by a febrile paroxysm, induced by the glandular inflammation just noticed; and which, from the first, discovers a tendency to recur, though often at irregular periods, so as to resemble an erratic intermittent. Every fresh attack adds considerably to the effusion, and consequently to the morbid size of the limb, and exacerbates every symptom; and hence the greater severity of this species than of the former, and the monstrous disfigurement of the leg and foot by which it is

flammation extends to the surrounding as well as to the descending parts; and hence the scrotum, like the pubes in puerperal bucnemia, is often peculiarly affected and distended to an enormous magnitude; while, occasionally, the glands of the axilla participate with those of the groin, and the forearm becomes also enlarged In a few instances, the disease is said to have commenced in the axilla; but such cases are very rare, and not well established.

In this manner the disease at length assumes a chronic character: the monstrous size and bloated wrinkles of the leg are rendered permanent; the pain, felt acutely at first, subsides gradually, and the brawny skin is altogether insensible. Yet, even from the first, except du ring the recurrence of the febrile paroxysms, the patient's constitution and general functions are little disturbed: and he sometimes lives to an advanced age, incommoded only by car rying about such a troublesome load of leg; which, however, as we have noticed already, is regarded in the Polynesian Isles as a badge of honour.

In our own country, the disease is rarely met with but in its confirmed and inveterate state, after repeated attacks of fever and effusion have completely altered the organization of the in teguments, and rendered the limb altogether incurable. In this state, the distended skin is hard, firm, and peculiarly thickened, and even horny; while the muscles, tendons, ligaments, and bones are, for the most part, little affected. [Most of the cases noticed in London are in Africans. The editor has seen one or two such examples in St. Bartholomew's Hospital. The most remarkable of these was published in one of the early volumes of the Medical and Phys ical Journal.]

In this advanced stage, the disease seems to be altogether hopeless: nor in any stage the practice hitherto pursued been productive of striking success. This has consisted chiefly in endeavours to alleviate the febrile paroxysms by laxatives and diaphoretics, and subsequently be better, perhaps, by active and repeated bleedto strengthen the system by the bark. It would

gatives, to endeavour to carry off the whole of the first effusion as quickly as possible; and then to direct our attention to a prevention of the paroxysms to which the constitution appears to be peculiarly subject, after a single one has taken place, by prohibiting exposure to the damp air of the evening, and by the use of tonics

* Trans. of the King's and Queen's College of Physicians, vol. v., p. 56. A woman died in La Charité in 1820, with what Andral calls elephan-ings, as well general as local, and powerful pur tiasis of one of her lower extremities, but which, probably, corresponded to the cases arranged by Dr. Good under the present title. The muscles were found, after death, reduced to a few pale, slender fasciculi; but the cellular substance was converted into an enormous mass, very hard, and including in some places cells filled with a serous fluid. At certain points it had all the physical qualities of cartilage.-(Anat. Pathol., tom. i., P. 277.) The same author has also seen an extraordinary ossification of the layers of the intermuscular cellular tissue, in the leg of a subject that died with bucnemia. The muscles were in the state of atrophy. The osseous matter, which was deposited in the spaces between the layers of muscles, was blended, in the deeper part of the limb, with bony vegetations arising from the periosteum. -Vol. cit., p. 297.

See the editor's Dict. of Practical Surgery, art. SCROTUM, published by Harper & Brothers, New-York, 1834.

in which the integuments of the legs were Latch An original and chronic affection of this kind, thickened, the limbs swelled to such an extent as to prevent the patient from walking, and in crusted with such a vast quantity of brawny scurf and scales, that handfuls of them might be taken out of his bed every morning, was suc cessfully attacked many years ago by a mistake of one plant for another. The case is related by Dr. Pulteney; and the patient, who had been recommended to swallow a table-spoonful of the juice of the water-parsnip, with two

a striking fact, that one of the severest illnesses that attacked Mr. Hunter's own person, and which ultimately proved to be disguised gout, podagrala rvata, he suspected, in its onset, to be a rheumatic ailment. The case, as given by Sir Everard Home, in his life of Mr. Hunter, is highly interesting and curious, as showing the singular forms which this morbid Proteus sometimes affects, and the various seats it occupies; as also, that a life of abstemiousness and activity is no certain security against its attack; for Mr. Hunter had at this time drunk no wine for four or five years, and allowed himself but little sleep at night.

Arthrosia, therefore, as a genus, may, I think, be fairly allowed to embrace the following speies:

Lumbago.

Coxendicis.
Sciatica.

¿ Thoracis.

Pain felt chiefly in the joints
and muscles of the extrem-

ities.

Pain felt chiefly in the loins;
and mostly shooting up-
wards.

in very young children, and, out of one hundred rheumatic patients, ninety are above the age of sixteen. The following is the result of what was noticed in relation to this point by M. Chomel, in La Charité. Out cf seventy-three patients attacked by rheumatism, thirty-five were between the ages of fifteen and thirty, twenty-two between thirty and forty-five; seven between forty-five and sixty; seven were turned sixty; and only two were under fifteen.

Daily experience proves that both sexes are subject to rheumatism. If women more fre quently escape from it, owing perhaps to thei less rcbust constitutions, and their being generally less exposed to cold and damp than the other sex, they are stil! known to be particularly liable to it when, after being tenderly brought up, they are exposed to the exciting causes; and their tendency to be attacked by it is known to be increased by interruption of the menstrual discharge. Hence, also, women between the ages of forty and fifty frequently suffer from it. Rheumatism is not so prevalent in certain families as gout; in other terms, it is less hereditary. Yet, though the disease can hardly be called hereditary, an individual born of rheumatic parents will certainly be in greater risk of suffer. ing from the complaint than another person whose parents were quite healthy. According to a table kept by M. Chomel, out of seventy. two rheumatic patients, thirty-six had rheumatic parents, twenty-four had healthy parents, and twelve could furnish no information on the subject.] How far the observation of Sir C. Wintringham is true, that those who have suffered amputation are susceptible of this disease more than others (Comment. de Moriss quibusdam, art. 79), the author cannot say from. his own practice; but it is the remark of a physician who was not accustomed to form a hasty judgment.

ments.

[The generality of writers, down to the he Pain felt chiefly in the hip-ginning of the present century, admit that the joint, producing emaciseat of rheumatism may be either in the muscles ation of the nates on the or the fibrous tissues, so called by Bichat, conside affected, or an elon- sisting of the capsules of the joints, fibrous gation of the limb. sheaths, the periosteum, and other fibrous mem Pain felt chiefly in the mus- branes, the aponeuroses, tendons, and ligaSpurious pleurisy. cles of the diaphragm, Hoffman, A. Leroy, and Pinel; to whom is to This is the doctrine of Rivière, F. often producing pleurisy of the diaphragm. be added M. Chomel. Among those who be lieve that rheumatism may be seated indiffer ently, either in the muscular system or the fibrous, some conceive that the disease never extends to the muscles but secondarily, and that it always first attacks the fibrous or ligament ous structures. Dr. Clutterbuck, in his lectures, even defines rheumatism to be an inflammation of the ligamentous structure, connected with the different joints, and covering the muscles at tached to them; which is in fact the theory of Bichat. Dr. Scudamore, who regards the tendinous portions of the muscles as the seat of rheumatism, believes that, if the muscular fibres were inflamed, they would be affected with swelling, which is not the case, while an increase of volume is always observable in the fibrous structures attacked. In opposition to the

:

The common remote cause of ARTICULAR RHEUMATISM, as of all the other varieties, is cold or damp applied when the body is heated though it may possibly be produced by any other cause of inflammatory fever, where the constitution has a peculiar tendency to a rheumatic action. This tendency or diathesis seems to exist chiefly in the strong, the young, and the active; for, though it may attack persons of every age and habit, these are principally its victims. We may hence, as well as from its symptoms, prove rheumatism to be an inflammatory disease. "Even in the weak and emaciated," observes Dr. Parr, "the pulse is hard, the blood coriaceous, and bleeding often indispensable." [Rheumatism is seldom met with

hypothesis of Dr. C. Smyth, that the essential seat of rheumatism is in the muscles, Dr. Scudamore does not consider the permanent weakness of these organs, the diminution in their size, the imperfection of their action, and the pain following their contraction, as proofs of the inflammation having its seat in the muscular fibres; but only as the consequences of the impairment of the synovial and tendinous structures, and of the extension or disturbance of these textures in a state of inflammation, whenever the muscles are put in action.

its peculiar inflammation does not continue long enough in any one organ to injure the structure of the arterial tunics; often, in effect, as in gout, we witness its disappearance in a moment, and find it migrating to some other part of the body. As a general rule, it may be asserted, that rheumatic inflammation does not tend to suppuration. [It is one of the characters of the fibrous system hardly ever to suppurate. Bichat believed that rheumatic inflammation never ended in the formation of an abscess, though coagulable lymph might be sometimes effused Acute rheumatism chiefly attacks the fibrous round the tendons affected.] In a few rare inparts of the large joints of the shoulder, hip, stances, the contrary has been known to take knee, elbow, &c., and the muscular aponeuro-place (Morgagni, De Sed. et Caus. Morb., ep. ses. This inflammation is not in reality attend-Ivii., art. 20; Med. Comment. Edin., vol. iv., ed with much swelling of the texture 'essential- p. 198); and, in one or two cases, I have myly affected, the density of which prevents any self been a witness to an extensive abscess. considerable effusion of lymph into its intersti- But the general rule is not disturbed by such ces. It is true, however, as Dr. Clutterbuck rare exceptions. The inflammation, therefore, has remarked, that a good deal of swelling often is of a peculiar kind. There will often, indeed, attends acute rheumatism; but this is owing to be effusion, and the limb will swell considthe extension of the inflammation into the sur-erably; but the effused fluid is gradually absorbrounding cellular texture.] ed, and the swelling not unfrequently, though not always, is accompanied with an alleviation of the pain.

A few years ago, the proximate cause of rheumatism was imputed to inflammation of the arteries themselves of the muscles and tendons; in short, to an immediate arteritis. Some cases and dissections, in support of this doctrine, were brought forward in France by M. Barde (Obs. communiquées à la Société de Méd.), and MM. Dalbant and Vaidy (Dict. des Sciences Med. Journ. Compl., vi., Août, 1819); but the anomalous diseases to which they refer have not been generally received as examples of rheu

matism.

In the case related by Mr. Barde, the heart, all the larger arteries, and even the vena cava, gave evident proofs of inflammatory action. Their coats were thickened, hardened, of a dark-red colour, in some parts covered with a whitish purulent matter, and in some the interior tunic was destroyed: the heart itself being considerably enlarged and inflamed.

Sometimes the pains take the precedency of the fever; but, in other cases, the fever appears first, and the local affection does not discover itself till a few days afterward.* There is no joint, except perhaps the extreme and minute joints of the fingers and toes, but is susceptible of its attack, although it usually commences in, and even confines itself to, the larger. Among these, however, it frequently wanders most capriciously, passing rapidly from the shoulders to the elbows, wrists, loins, hips, knees, or ankles, without observing any order, or enabling us in any way to prognosticate its course; always enlarging the part on which it alights, and rendering it peculiarly tender to the touch. The urine is often at first pale, but soon becomes high-coloured, and deposites a red sediment. It may be distinguished from gout by [The foregoing hypothesis of arteritis being being little connected with dyspepsy, commenthe proximate cause of acute rheumatism, is suf- cing less suddenly, evincing more regularly-markficiently refuted by the consideration, that, if ed exacerbations at night, but less clear remisit were true, rheumatism would always accom- sions at any time to which we may add, its pany arterial inflammation, which is not the fact. attachment to the larger, rather than the smallIf another argument were required to subvert er joints; and its connexion with exposure to the opinion, it might be readily found in the fly-cold and damp. It runs on from a fortnight to ing and very wandering nature of rheumatic three weeks; and the average of the pulse is pains, which pass, as Bichat (Anat. Gén., tom. rarely under a hundred. ii., p. 263) expresses himself, with astonishing quickness, from one situation to another. Broussais, in his Leçons Pathologiques, thus accounts for rheumatism: "When," says he, "the action of the skin is diminished, it is determined to another part; and here it is to the capsules or articular ligaments, the textures around the joints, that the irritation is determined."]

In the general course of acute rheumatism,

*The parts are generally hot and red, and frequently the pain is situated in the theca of the tendons: Dr. Elliotson has noticed red streaks in the direction of the latter parts.-Lect. at Lond. Univ.. as published in Med. Gaz. for 1833, p. 852.-ED.

The fever is generally accompanied with copious and clammy sweats [often of an exceedingly sour smell]; but the skin still feels tense and harsh; nor does the sweat issue freely from

* Acute rheumatism presents a state of active fever, accompanied with inflammation of the fibrous tissues about the joints. One point not entirely decided is, whether the fever is the cause or the effect of the inflammation? Sydenham adopted the first of these views, which has found an able advocate in Dr. Barlow (Cyclop. of Pract. Med., art. RHEUMATISM), who endeavours to prove (a fact generally acknowledged) that the state of the constitution is what principally claims regard in the treatment of acute rheumatism -ED.

the immediate seat of pain. It seems to be an | camphire. Aperients are useful to a certain ex ineffectual effort of the remedial power of na- tent; but they have not been found so service ture to carry off the complaint: for it is by this able as in various other infiammations. Small evacuation alone that we can at length succeed doses of calomel have occasionally, however, in effecting a cure. But the perspiration will seemed to shorten the term of the disease, though be always found unavailing, so long as it contin- they have not much influence in diminishing the ues clammy, and the skin feels harsh, and there pain. To obtain this, Dr. Hamilton has comis a sense of chilliness creeping over the body, bined calomel with opium; and, in his hands, or any part of it, during the perspirable stage. it appears to have been successful. Opium The exacerbation, which regularly returns in alone is rather injurious; nor has any decided the evening, increases during the night, at which benefit resulted from other narcotics, as hyostime the pains become most severe; and are cyamus, hemlock, and aconite. then chiefly disposed to shift from one joint to another. *

[Acute rheumatism is not, generally speaking, attended with danger. Sometimes, however, it induces inflammation in parts of great importance to life; seemingly, in consequence of their partaking more or less of the ligamentous or fibrous tissue. The periosteum is a structure that is frequently attacked; and hence those aching pains in the bones by which patients are severely tortured. The pericardium is another organ to which rheumatic inflammation is frequently directed: the case being indicated by great pain in the region of the heart, and great disorder in the action of this viscus. Sometimes the dura mater, another fibrous membrane, suffers; the patient being afflicted with severe headache and delirium, and often falling a victim to the disease. There is also no doubt, that the pleura and diaphragm are very liable to acute rheumatic inflamination; and surgeons mest experienced in diseases of the eye, recognise a species of rheumatic inflammation to which that organ is subject, and which has its seat in the sclerotic coat, whose fibrous texture is well known. Frequently it affects the loins, producing lumbago; the muscles at the back of the neck, the face, or any other part, where fibrous membranes, aponeuroses, ligaments, tendons, or perhaps muscles, are situated.]

No constitution is invulnerable to the attack of rheumatism, although the young and the rig orous 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 being useful. Local bleeding is here to be preferred, but it cannot be depended upon; since, though the pain may diminish, or even totally subside, it is in many cases only to make its appearance in some other quarter.* Here also, if in any case, we have rea son to expect benefit from uniting stimulants with diaphoretics, as ammonia, camphire, and the resinous gums and balsams.

In such habits, and particularly if opium should disagree with the system, it may be worth while to try the rhododendron (r. Chrysanthum, Lin.), This plant is a native of the snowy summits of the Alps and mountains of Siberia; and in Rus sia, 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 (Med. Comment., vol. v., p. 434): in conse quence of which, it has formed an article in the Materia Medica of the Russian Pharmacopoes for nearly a century. Dr. Home tried it upon a pretty extensive scale in the Edinburgh Infir mary, and found that it acts both as a powerful Where fever is violent, and especially where diaphoretic and narcotic; and is at the same the frame is robust, our only effectual remedies time one of the most effective sedatives in the are copious bleeding and the use of diaphoret- vegetable kingdom. In most of the cases it ics: by the former, which will often demand retarded the pulse very considerably, and, in repetition, we take off the inflammatory diathe- one instance, reduced it to thirty-eight strokes sis; and by the latter, we follow up the indica-in a minute. It has also the advantage of occa tion which nature herself seems to point out, sionally proving aperient. But it sometimes and endeavour, by still farther relaxing the ex-produces vertigo and nausea; and, as a general tremities of the capillaries, to render that effectual, which, without such collateral assistance, is, as already observed, for the most part exerted in vain, and with an unprofitable expenditure of strength. The most useful diaphoretic is Dover's powder; and its benefit will often be increased if employed in union with the acetated ammonia, and sometimes if combined with

* When the disease subsides, the parts do not desquamate and itch, as they do after gout; but they merely cease to be hot, swollen, and inflamed. (Dr. Elliotson's Lectures.) Rheumatism does not begin, like gout, particularly in the nighttime; and it arises from an evident exciting cause, exposure to cold, or cold and wet, which is not the usual occasion of gout. In the latter disease, you have not, in the early stage, the same tendency to profuse and often sour perspirations.-ED.

medicine, is not to be preferred to Dover's powder (Clinical Experiments, Histories of Dis sections, 8vo., Edin., 1780), or even the antimonial powder with opium, where the latter can be borne without inconvenience.

It is possible also in habits of this irritable kind, if in any, that we are to look for that ex traordinary and decisive benefit from a free use of the bark at an early period of the disease, which we are told has been obtained. Contem

* Dr. Elliotson finds that free local bleeding gen erally answers better than venesection; and he observes, that whether leeches or cupping be em ployed, great benefit will result from applying cold lotions as long as the temperature of the part is higher than it ought to he-See his Lectures at the Lond. Univ., as published in the Med. Gaz for 1833, p. 853.-ED.