for if their powers be enfeebled by reducing their mode of living, the debility thus induced renders them only the more susceptible; though in all a single debauch may bring their enemy suddenly upon them. Gout in the stomach, whether it attack the organ by retrocession, or whether it arise there primarily, is always attended by imminent danger. It does not, indeed, appear that the affection is of an active inflammatory character, since it is most commonly relieved by stimulants, and threatens death by syncope; it is probably in the form of an asthenic hyperæmia. When the symptoms of this affection present themselves, our first business should be to ascertain if any indigestible food has been taken; since, as Dr. Watson remarks, gout in the stomach may turn out to be pork in the stomach. Yet it is possible, upon the principles already laid down, that the latter may excite the former. When there is reason to believe that such matters are present, an emetic should be administered; and afterwards the magnesia draught (15), with about ten minims of laudanum; if this fail, a glass of brandy will sometimes allay the pain completely.

BEFORE We commence the consideration of the diseases of either of the three great cavities of the body, as they are termed-namely, the cranium, the thorax, and the abdomen-it may be well to call to mind that each of the viscera contained in any one of these cavities is differently circumstanced from those in either of the others, in regard to the degree in which they are accessible to our examination of their physical condition. The viscera enclosed within the cavity of the cranium, are screened by its bony walls from our manipulation, and, therefore, we are confined in our endeavours to ascertain the seat and nature of any disease which may be going on within them, to the use, first, of those general, or as they are termed, constitutional signs by which we judge of the existence of inflammatory or other disease, and secondly, of the disturbance or non-performance of the function (the lasa partis functio) of any particular part or organ; but we are unable to appreciate, and consequently to derive any assistance from the physical changes in that part, which the disease may have induced.

The viscera of the abdomen again are contained in a cavity, the walls of which, for at least two-thirds of their surface, yield readily to the pressure of the hand, and, consequently, enable us to detect changes which disease may have produced in the size or hardness of their contents. We are also enabled, from the same circumstances, to detect any tenderness which inflammation may have excited, and thus obtain further important information as to the nature, the seat, and the extent of the disease; and by the use of percussion to detect any variation in the solidity of the viscera, a matter of great importance in regard to the hollow alimentary canal.

The viscera of the chest again are differently circumstanced in the above respects from those of either of the other cavities. They are, indeed, excepting where its cavity is separated, by the diaphragm, from the abdomen, and at the comparatively small space above, included between the two first ribs, the vertebræ, and the first bone of the sternum, enclosed within walls rendered rigid by bone or cartilage, and, therefore, withdrawn almost as completely as the brain from every attempt to determine any change in their physical condition by means of the hand: this is, perhaps, one reason why there was, till within the last thirty years, the greatest difficulty in determining not only the seat or character, but often the very existence of disease within the chest. Since, however, the happy thought which had before suggested itself to Avenbrügger (and there is some ground for suspecting even to Hippocrates), of applying another sense, that, namely, of hearing, to the investigation of disease, was realized and made practically available by Laennec, a complete revolution has

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

excretory matter acting as a poison; (3) to correct the mal-assimilation, and so prevent the undue formation of uric acid, or at all events, promote its conversion into the more soluble matter urea, which is more readily carried out of the system. To these may be added the specific treatment; and finally, we shall give the plan of treatment which we consider deserving the greatest confidence.

The first indication suggests decided antiphlogistic measures, and undoubtedly they are not without their use. Of these the most obvious is bleeding; and in a plethoric subject, with a strong pulse, a full bleeding at the commencement of the disease often goes a great way to arrest its progress, or at all events to render it more amenable to other remedies. But the frequent repetition of the bleeding is most objectionable: we would advise that it should never be repeated beyond a second time, if so often, unless in the case of cardiac or other internal inflammation; since it renders the patient more liable to that terrible malady sub-acute synovial rheumatism: it is also contraindicated by the tendency of the disease itself to produce anæmia, or defect of red blood, which is favoured by venesection. Purging is another antiphlogistic measure of considerable service; but when carried to the extent of five or six loose motions daily, it has more the character of the eliminating plan of treatment. Antimonials are useful in the same way. The great suffering, however, suggests the use of opium, which in combination with the antimony, and a little calomel, may be regarded as an antiphlogistic means; and by thesethe bleeding at first-the antimonials with salines-the opium and calomel, with a little additional antimony, the patient may generally be carried well through the disease; but, as Dr. Alison observes, "the acute rheumatism cannot probably be much shortened in its duration by antiphlogistic remedies." We may also add, that mercury cannot be relied upon as an antiphlogistic measure to the extent to which it can, in other phlegmasiæ; and it is particularly liable to the objection that it diminishes the quantity of red corpuscles.

We have just spoken of opium, and have alluded to the extensive implication of the nervous system in rheumatism; and towards obviating excitement in, or implication of the sentient extremities of the nerves in this disease it presents an efficient means; and opium alone, in grain doses, repeated every three hours, will sometimes cut short an acute rheumatism in a very few days, but it is hardly safe unless combined with evacuants. In the case of a sound subject, a full bleeding, a purgative, and the opium treatment will often act almost heroically.

Various specifics have been recommended in rheumatism, of these the most conspicuous are bark and colchium; of bark and quinia it may be affirmed, that in the acute stage of the disease they are inadadmissible, though when the inflammation has been subdued, and the pains have at all a periodic character, the bark and soda, or (if there be excessive perspiration without mitigation of the symptoms) quinia and acids will be very beneficial, though their employment is more appropriate to the sub-acute form.

Colchicum has, no doubt, great power over rheumatic inflamma