it is not till youth or early manhood that the lungs, which are nevertheless in the aggregate peculiarly obnoxious to tubercles, acquire their full liability to them. On the same principle we find that the presence of tuberculous matter is very common in the spleen in children, in whom, from their extremely active habits, that organ is frequently liable to great sanguineous engorgement. Further, it has been observed that tubercles are scarcely ever found in the organs of reproduction before the age of puberty, though their occurrence after that period (that is, after those organs have attained their maximum of vascular and functional activity) is by no means infrequent. In the intestinal tube, again, tuberculous disease is a common occurrence, and it is worthy of notice, that in the majority of cases it is confined to the lower portion of the ileum and the caput cœcum coli, parts of the canal which appear, from their being most frequently the seat of hyperæmia and mucous inflammation in the course of other diseases, to be peculiarly susceptible of vascular excitement.

The effects of climate, in favouring or counteracting the deposition. of tubercles in the lungs, will afford another illustration of the same law, since it is in colder climates that there is the greatest demand for the function of respiration, and consequently the greatest functional activity and most rapid flow of blood through the lungs; and the increase of such activity, occurring when animals or human beings are removed from a warm to a cold climate, might be expected to act still more powerfully upon the lungs, which have been less developed from a less performance of function; and this is found to be a circumstance peculiarly favourable to the deposition of tubercles in these organs. This, however, is a question that will require a fuller consideration in connexion with the subject of phthisis. It may, however, be well here to cite the words of Dr. Alson, that it is a "well-ascertained fact that masons, miners, needle-grinders, and other artificers who are in the habit of very frequently inhaling irritating particles, are peculiarly liable to scrofulous phthisis."

From what has been stated it is evident that tubercles may be deposited independently of inflammation, and also that inflammation may occur in subjects, in whom that deposit already exists-and that too around the tubercles, and in their immediate neighbourhood, without the effused matter assuming the form of tubercle-whence we infer that there is no necessary connexion between inflammation and tubercle; at the same time it is also evident, from the circumstance of the tubercular deposit being generally promoted by an increased afflux of blood to the part so affected, that inflammation, by inducing such an afflux, must have a tendency to excite the formation of tubercles.

It must be apparent from the description already given, that the occurrence of inflammation in scrofulous subjects cannot be too cautiously guarded against, and therefore a most important consideration in the management of such subjects, is the prophylaxis or previous guarding or fortifying the patient against it (from ape and passo, I guard or defend): for this purpose two objects are to be

kept steadily in view: 1, the obviating the morbidly-defective vitality of the blood with deficiency of fibrine, which appears to be one of the fundamental conditions of the scrofulous diathesis; and 2, the removal of all circumstances which tend to excite inflammation, or local congestion. The general principles, upon which the first of these objects is to be pursued, will be readily understood from what has been said of the circumstances favouring the development of those conditions, which constitute the scrofulous diathesis: the particular application of these principles will be more appropriately considered when treating of special diseases.

The second of the above objects will be most likely to be attained by not only avoiding the ordinary causes of inflammation, but also by paying particular attention to those circumstances and conditions which have been already pointed out as favouring, at the same time, the occurrence of congestion, and the development of tubercle in scrofulous subjects, and adopting measures to obviate them.

When, however, inflammation does occur in such subjects, it must be met by early but moderate antiphlogistic treatment, since it is of the first importance to prevent it going on to produce any of the inflammatory effusions, which, under such circumstances, are not merely apt to assume an unorganisable character, but often tend to prevent the nutrition of the surrounding textures. It unfortunately happens, nevertheless, that these effusions do most commonly take place, either in the form of the cheesy matter already described, the white granular albuminous matter, or tubercle: and since the effusion of these matters is not controlled by the same constitutional remedies which check the effusion, or promote the absorption of inflammatory lymph in ordinary inflammation, but is rather aggravated by them, and the consequent disorganisation of the surrounding tissues accelerated, the same line of treatment cannot be persisted in; and all measures which, by lowering the powers of the patient, and impairing the vitality of the blood, may be supposed to favour suppuration or ulceration, should be suspended, as soon as there is reason for believing that any of the above deposits have taken place; and a moderately tonic treatment substituted, the means for reducing inflammation being restricted almost entirely to counter-irritants.

It is, perhaps, after the more acute inflammatory action has subsided, and when the above-named deposits are taking place that iodine, or rather the iodide of potassium, is peculiarly serviceable: its power of preventing the separation of true tubercle is, to say the least, very questionable; but if it do not actually effect the absorption of the albuminous deposit, it checks its effusion, probably by its influence in improving the condition of the blood.

CHARACTER OF RHEUMATISM.

115

VIII.

RIIEUMATIC AND GOUTY INFLAMMATION.

UNDER the term rheumatism are included several diseases, which vary in every respect, except one, which is their being always painful. It is by no means improbable that these diseases, which have received a common name, are essentially different. To avoid as much as possible this confusion, we commence with the unquestionable form of the disease, acute rheumatism, rheumatic fever, or, as it is sometimes called, rheumatitis.

Acute rheumatism, then, is a specific inflammation, affecting almost exclusively fibrous tissues, though sometimes extending to the surrounding structures by contiguity. It attacks chiefly the larger joints, especially the knees, wrists, shoulders, elbows, and ankles. The external cause is generally exposure to cold, especially when producing repressed perspiration. Its internal or essential cause seems to be an abnormal condition of the blood, which contains always an excess of fibrine and of uric acid: the latter is probably the materies morbi or peccant matter.

Acute rheumatism commences with the ordinary premonitory signs of inflammation, rigors, heat, thirst, restlessness, and anxiety, speedily followed by severe pains attacking the larger joints. These pains are ordinarily very severe, following much the course of the muscles, and producing such extreme tenderness that the weight of the bed-clothes can hardly be borne, and motion of an affected joint is intolerable anguish. The swollen joint is usually red and puffy; the swelling is, however, more certainly present than the redness. The constitution in the mean time shows signs of active inflammatory fever; the tongue is covered with a white fur; the pulse is sharp, bounding, and not yielding readily to pressure; the urine is scanty, and the bowels generally torpid; the skin, however, is commonly bedewed with an unctuous perspiration, which has a peculiar acid odour, which it is difficult not to recognise. The inflammation, instead of running the ordinary course of common inflammation, is exceedingly erratic, or liable to metastasis, as it has been termed, suddenly leaving one part and attacking another: sometimes the part to which it transfers itself is an internal fibrous structure, and of these the most liable to be attacked is the pericardium; the substance of the heart also is probably liable to be implicated, and next to the pericardium, the endocardium, particularly the valves of the left side of the heart, is most susceptible. The other membranesthe pleura, peritoneum, dura mater, and tunica vaginalis-may also be attacked. It is, however, the tendency to metastasis to the heart which constitutes the great danger of the disease; not that it is necessary that the inflammation should leave the extremities that the heart should become affected, for the heart affection as commonly

supervenes without subsidence of rheumatic inflammation in the joints as with it, or even more so. The ordinary termination is resolution; but true rheumatic inflammation never leads to suppuration or gangrene, nor, when it is in the extremities, to adhesion; when, however, it attacks the pericardium or other internal part, it runs the same course as common inflammation. Sometimes there is a copious effusion of fluid into the synovial capsules and sheaths of tendons, especially the capsules of the knee. This difference has led to a distinction between fibrous and synovial rheumatism. The true acute rheumatism is, however, generally of the former kind, the latter being a more sub-acute form, and often a sequela of the acute.

The external cause is, as has been stated, exposure to cold, and repressed perspiration; there are, however, no doubt some persons constitutionally liable to this disease, which also seems to prevail more in particular seasons than in others; generally, but not universally, when the weather is cold, damp, and variable. The disease generally attacks young persons, prevailing most in youth and early manhood. After thirty-five it becomes less common; though cases do occur at all ages, and even young children are not exempt. It is generally believed that the tendency to affect the heart is greatest before puberty, and some have gone so far as to assert that no young persons under that age ever get through an attack of acute rheumatism without that organ being more or less involved.

The robust and plethoric, are also said to be more liable than others to attacks of rheumatism; though the experience of our London hospitals hardly warrants such a conclusion, since it is a common disease amongst the London poor, who are not generally very robust or plethoric; and it attacks females, and delicate females too no less than

men.

The sub-acute rheumatism, to which we have before alluded under the term synovial, is often a sequela of the acute, though it may arise primarily. It attacks the same structures, and often produces great deformity and distortion: the joints become enlarged from the effusion into the capsular ligaments, and the muscles waste. It is perhaps more common to see it affecting the smaller joints than is the case with acute rheumatism; and probably on this account it is often known by the name of rheumatic gout, and not without reason, for it is perhaps the connecting link between the two diseases. When long continued, it produces stiffness of the joints, amounting in some cases to perfect immobility, and they are distorted as if actually displaced. This is particularly the case when the disease attacks the fingers.

The above constitute the diseases to which the term rheumatism ought to be restricted. The chronic rheumatism or rheumatic pains belong to a distinct class; they may indeed have their origin sometimes in the same causes as true rheumatism, but as the former are essentially blood diseases, so the latter are essentially nervine; and therefore we shall speak of the so-called chronic rheumatism separately.

The diagnosis of acute and chronic rheumatism is generally pretty obvious the severe pains, the swelling, the febrile excitement which accompany the former can seldom be mistaken; yet these are not to be implicitly relied upon unless the rheumatic odour be also present, since cases have occurred in which the arthritic pains and swelling, closely simulating rheumatism, have occurred as the result of irritation of the nervous centres. In one remarkable case, in Guy's Hospital, which closely simulated acute rheumatism, the primary disease was inflammation of the cervical portion of the medulla spinalis. Cases like this are of rare occurrence, but they are of great interest, as showing the possible nervine origin of even acute inflammation; and they readily explain how the pains which are so hastily included under the term rheumatism may be in reality nervine

affections.

The danger of rheumatism as affecting life is in general but little, unless it attack the heart or other important internal organ; and, therefore, as such an occurrence is always possible, the prognosis should be guarded accordingly. As regards the probability of perfect recovery, the same liabilities are to be borne in mind, and therefore the condition of the heart cannot be too frequently or too carefully examined. We do not here enter into details which belong more to the special consideration of cardiac disease, which will be found elsewhere; but would merely insist upon the importance to be attached to every abnormal circumstance affecting the circulation, whether it be murmur-impulse-or deviation from the natural character of the pulse. And as regards any permanent ill effects from rheumatism, we must not forget the occasional occurrence of the sub-acute form of the disease (which would be more properly termed the chronic), producing the lamentable stiffness, immobility, and distortions already alluded to.

Rheumatism is a disease often resisting the best-selected remedies, and apparently running its course unchecked; so much so, that many authors of judgment and experience have expressed their opinion, that in most cases it will, in spite of remedies, run a course of five or six weeks, and that, notwithstanding many certain and speedy remedies. There are, however, certain modes of treatment which deserve special notice, and some upon which we believe great reliance may be placed. Here we would premise that (1) rheumatism is an inflammation; (2) that it originates in the presence of an excretory matter in the blood, produced probably in excessive quantity, through defective assimilation, or imperfect oxidation of the products of the interaction of the blood and the tissues (owing to which uric acid is formed in too great abundance in the extreme circulation, instead of urea); and further, (3) that though a blood disease, it nevertheless involves the nerves of sensation and voluntary motion more decidedly, if not more essentially, than ordinary phlegmasia, as is well pointed out by Dr. Addison, (Elements of Practice of Medicine, p. 576.)

Three prominent indications suggest themselves-(1) to subdue the inflammation, regarding it simply as such; (2) to eliminate the