has any disposition to change its seat, these measures are inappropriate. In the latter case, if any other application is made than a light covering of flannel, it should be something very lenient in its action, as emollient or anodyne cataplasms, mild camphorated lotions, &c. Some have recommended a covering of oiled silk, or thin layers of caoutchouc, so as to confine the perspiration of the part, and thus make a kind of vapour bath about it. Poultices with carbonate of soda are said often to prove beneficial.

Little can be done locally for the removal of the gouty concretions. When the part ulcerates, it should be dressed with poultices, and nature may be somewhat aided by mechanical, and possibly by chemical means, in removing the deposition; but not much can be done in this way, in consequence of the enclosure of the urate within the cells of the areolar tissue. Should gangrenous symptoms present themselves, the yeast poultice, or cataplasms made somewhat stimulating by the addition of creasote, or of some alcoholic liquor, as porter or beer, may be employed.

The nodosities that form upon the tendons and fascia will often yield to steady external counter-irritation, by means of the galbanum or ammoniac plaster, one of the turpentines, the ointment of iodine, or repeated blistering.

For the contraction of the muscles, and stiffening of the joints, little more can be done than to immerse the part frequently in warm water, to employ the hot douche occasionally, and to induce the patient, by frequent efforts of his own, to endeavour to regain his command over the movements of the limb. 3. NERVOUS GOUT.-This very diversified disease, which shows itself in almost all parts of the body, and in almost every variety of form, requires an equal diversity of treatment; and the ingenuity of the practitioner is often severely tried, to find out modes of relief which shall at the same time accord with his own sense of propriety, and the incessant demands of his patient. Much, however, can be done towards removing present symptoms, and obtaining a longer or shorter respite from suffering; and sometimes possibly the patient may surmount the disease; but, though life may be prolonged not unfrequently to old age, it is rare that an individual, constitutionally liable to the complaint, does not continue during life to be at times. more or less affected by it. I wish the reader to understand that the following observations apply as well to the rheumatic, as to the gouty affection.

One universal rule in these cases is, whenever the faintest disposition is shown by nature to give an external direction to the disease, to encourage her efforts by means calculated to attract irritation to the surface, and especially to the extremities. These have been already sufficiently detailed.

Much may be expected from a judicious use of medicines supposed to have an alterative influence over the disease, such as colchicum, guaiacum, aconite, veratria, arnica, sulphur, iodine, arsenic, &c.; care being taken, in their use, not to allow them materially to disturb the stomach or bowels.

When the system is anemic, as not unfrequently happens, recourse should be had to the preparations of iron, simple bitters, and a nutritious diet.

Whenever the disease is intermittent, no matter what form it may assume, whether that of neuralgic pain, spasm, or functional derangement of some one of the organs, provided there is any approach to regularity in the recurrence of the paroxysm, sulphate of quinia should be freely employed, and will almost always succeed very speedily. The practitioner may often spare his patient long and exquisite suffering, by being upon the watch for this intermittence, and prepared at once to take advantage of it. Not unfrequently, when at first quite irregular, it assumes the regular periodical form under the use of alterative or tonic treatment, and will then yield to the salt of quinia. Twelve, eighteen, or twenty-four grains, should be given between

the paroxysms, or even more, if required to bring on the peculiar cerebral phenomena which characterize the action of the medicine.

In the severe neuralgic forms, it often becomes absolutely necessary to have recourse to anodynes. When the attack is of some internal organ, as of the stomach, bowels, heart, &c., opium or some one of its preparations must be given, and often in very large doses, for example, double, triple, or quadruple the ordinary quantity, before relief can be obtained. The opiate may often be usefully combined with colchicum; and I am much in the habit, in these cases, of prescribing a mixture of solution of sulphate of morphia, and the wine of colchicum root. But whenever the urgency of the case will admit of having recourse to some other narcotic, and especially when the pains are external, one of these should be preferred to opium, from the great danger that the patient may be led into the habit of its abuse. The extracts of belladonna, stramonium, and conium, are often very efficient, especially the first. Chloroform may also be usefully employed in some

instances.

A very powerful remedy, in the purer neuralgic forms, is the subcarbonate of iron in large doses, say a drachm three or four times a day; and temporary cures will often be effected by the combined use of this medicine and the extract of belladonna. I think that I have seen more cases of pure gouty and rheumatic neuralgia, without inflammation, get well under this combination, than under any other single plan of treatment, except that of quinia in intermittent cases.

In these neuralgic forms, moreover, large doses of sulphate of quinia will often effect cures, even when there is no regular intermission. It will frequently be necessary to push the remedy to the extent of twenty-four or thirty grains in the twenty four hours. This is especially useful when the disease assumes the form of hemicrania; but in these, as well as in other cases, it may be advantageously combined with the oil of valerian. The effect of the remedy is not unfrequently to aggravate the headache, for the first day or two, after which the complaint gradually diminishes, and ceases altogether, in three or four days or a week. Hemicrania seldom fails to yield to this treatment.

It is scarcely necessary to follow the disease through the various internal organs; as the functional disorder which it produces in each closely resembles that proceeding from other causes, and requires the same treatment. Thus, when it attacks the stomach in the form of dyspepsia, or of gastrodynia, it must be treated exactly as those affections are usually treated. (See Diseases of the Stomach.) The same may be said of the form of colic, which it not unfrequently assumes. Deficient or deranged action of the liver, which is a very common attendant upon this, as well as other forms of gout, requires the occasional use of the mercurial pill or small doses of calomel, care being taken not to carry the remedy so far as to affect the gums. Nitro-muriatic acid is sometimes also very useful in these cases, but should not be given in connexion with the mercurial. Taraxacum and the alkalies now and then prove useful, and may be alternated with the other remedies. Constipation of the bowels should be obviated by laxatives, as rhubarb, sulphur, magnesia, Cheltenham salt, Saratoga water, &c., or by a regulation of the diet, as by the use of bran bread, tomatoes, &c. Nephritic disorder may be treated with the alkaline bicarbonates, and sometimes, when the urine is excesssive, by narcotics and astringents, or by terebinthinate remedies. Palpitations, and precordial oppression, will often yield to the aromatic spirit of ammonia, Hoffmann's anodyne, oil of valerian, assafetida, or musk; and dyspnoea, when purely spasmodic, may be treated in the same way.

In relation to all these affections, and others of analogous character, the general rules already given must be borne in mind, of relieving violent pains by opiates or other narcotics, of endeavouring to give an external direction to the disease by hot fomentations, rubefacients, blisters, &c., and of addressing remedies to the constitution with the view of subverting the disease, as colchicum, quinia, &c. Not unfrequently, also, even when there is no reason to believe that there is any inflammation, leeching in the neighbourhood of the part, or even the loss of blood from the arm, will afford great relief in painful internal affections. When the disease seizes upon the head, these last remedies are especially useful. Gouty or rheumatic headache often yields very happily to a few leeches or cups to the temples, or nape of the neck. But bleeding must always be used with some reserve; as, though it may afford relief, it does not eradicate the tendency, and, too frequently repeated, may produce an anemic condition, favourable to the perseverance of the disease. Another important fact to be borne in mind is, that, in many of these cases of disordered function and neuralgic pains, the real cause is an attack of the disease in the ligaments or internal membranes of the spinal column, producing irritation in the spinal marrow, and consequently derangement in all its dependent functions. In such cases, the remedies must be addressed especially to the spine.

Besides the local measures already referred to, various others may be used with much temporary benefit, in the more painful forms of the disease. Emollient, anodyne, and rubefacient embrocations or cataplasms; frictions with aconite, veratria, and colchicum, in ointment, or strong spirituous solution; plasters of belladonna and stramonium; morphia sprinkled on the skin denuded of the cuticle; chloroform in poultices, or applied by means of linen moistened with it, and protected from evaporation by a covering of oiled silk; have all been employed, and with excellent apparent results; but, in this affection, it is not always possible to determine how much is owing to the peculiar virtues of the remedy, how much to the mere process employed in its application, and how much to the mind of the patient. I have repeatedly known gentle and continued friction with the hand to dissipate the pain entirely for a time; and nothing is more common than for the same effect to follow any strong mental movement, whether emotional or intellectual.

In this variety of gout, it is especially necessary to invigorate the constitution; for which purpose moderate exercise, pure air, a nutritious but easily digested and unstimulating diet, the pleasures of agreeable social intercourse, and the avoidance of all excesses, whether mental or physical, are the chief measures to be relied on. More even than in chronic gout, will advantage accrue from travelling, frequenting the watering places, &c. Any plan of life, which, while it favours health in general, places the system of the patient under entirely new influences, will often prove of the greatest benefit, and sometimes completely renovate the constitution. Hence the advantages of a foreign tour and residence. Hence the wonderful revolution sometimes effected in the health by a change of fortune, which reduces the patient from the luxuries, indolence, and self-indulgences of wealth, to the necessity of daily exertion for a livelihood. Hence, probably, also, in part, the advantage which has frequently accrued, in such cases, from the famous water-cure.

CLASS III.

LOCAL DISEASES.

This is much the largest of the three classes' in which diseases are arranged in the present treatise. It embraces all those which have their seat primarily or essentially in any one organ, tissue, or function. The local affection is often accompanied with constitutional symptoms; but these are secondary, as in the phlegmasiæ, in which the fever depends upon the inflammation. It is true that, among the following diseases, are also many which are results of constitutional derangement; but, in these instances, the local affection is so striking and important as chiefly to engage attention, and always to have ranked among diseases, with a distinct title; while the constitutional disorder, from which it may have sprung, is often concealed and unknown. Such are the local tuberculous affections, many instances of dropsy, and not a few cutaneous eruptions. I have preferred the several functions as the basis of arrangement in this class, to the regions of the body; because it often happens that a particular disease, though confined to one function, overleaps the region, and may in fact occupy several regions, as dropsy occurring at the same time in the chest, abdomen, and external areolar tissue. In the order of the functions, I begin with that which nature has placed first and lowest in the scale, and follow her course through the remainder. Pursuant to this plan, the diseases connected with the digestive system come first in order; then those of the absorbent system; and afterwards successively those of the respiratory, circulatory, secretory, and nervous. Diseases of the reproductive system, so far as they peculiarly belong to it, come generally under the care of the surgeon or ob

stetrician.

In each group of diseases, those which consist in inflammation of the parts concerned are first treated of; because they are in general better understood and more easily recognized, and consequently, when known, serve as standards of comparison for the more obscure functional affections.

SECTION I.

DISEASES OF THE DIGESTIVE SYSTEM.

These are most conveniently distributed into minor groups, connected severally with distinct portions of the digestive tube. The first embraces diseases of the mouth, the second those of the fauces, pharynx, and oesophagus, the third those of the stomach, and the fourth those of the bowels. But, as there are several affections which occupy the stomach and bowels jointly, a fifth group is made, including such diseases, together with those of the peritoneum, which may be considered as an appendage.

SUBSECTION I.

DISEASES OF THE MOUTH.

In this subdivision are included, 1. the different forms of inflammation of the mucous membrane of the mouth; 2. inflammation of the tongue; 3. morbid states of dentition; and 4. diseases of the teeth, under the general heads of toothache and falling of the teeth.

Article I.

INFLAMMATION OF THE MOUTH, or STOMATITIS.

The term stomatitis (from aroua, mouth) is applied to inflammation of the mucous membrane of the mouth. The disease appears under various forms. The inflammation may be diffused equably over portions or the whole of the membrane, or may occupy chiefly or exclusively the mucous follicles. When diffused, it may present no peculiar secretory product, or may cover the surface with a consistent curd-like, or a pseudo-membranous exudation. It may be attended with eruption, ulceration, or gangrene, and receive from each of these attendants the character of a distinct variety. In fine, it may be реси. liar from the nature of the cause, as when it accompanies scurvy, or is the result of mercurial action. It will be most convenient to treat of each of these forms separately.

1. COMMON DIFFUSED INFLAMMATION.-This appears in reddened somewhat elevated patches, or occupies large portions of the surface, sometimes extending apparently over the whole mouth. In some cases, it is superficial, with little or no swelling, and may be designated as erythematous; in others, it occupies the whole thickness of the membrane, extending sometimes to the submucous tissue, and even to neighbouring structures, as the sublingual and submaxillary glands, and the absorbent glands of the neck, and occasions considerable tumefaction in all these parts. In the erythematous form, it is characterized by redness, a sense of heat, and sometimes considerable tenderness, but is not usually attended with acute pain; when deeper in the tissue, it is often very painful. Portions of the epithelium sometimes become opaque, giving an appearance of whiteness in streaks or patches. Occasionally this coating is elevated in blisters, or even detached like the cuticle from the skin in scalds. Superficial ulcerations not unfrequently occur, which may spread over considerable portions of the membrane. In certain states of the constitution, the ulcerative tendency is very strong, and deep and extensive sores occur, which are sometimes attended with gangrene. There is often a copious flow of saliva; though, in some instances, this secretion, as well as that of the mucous follicles, is checked, and the mouth is clammy or dry. The sense of taste is usually more or less impaired, and speech and mastication are often difficult and painful. When the tongue is affected, its surface is in general at first covered with a whitish fur, through which the red and swollen follicles may often be seen projecting. The fur sometimes breaks off, leaving the surface red, smooth, and glossy, with here and there prominent follicles, and very sensitive to the contact of even mild substances; or the surface may be dry, hard, and gashed with painful fissures. When the gums are involved, they swell, and rise up between the teeth, around the neck of which they not unfrequently ulcerate. In some rare instances, this ulceration is very obstinate, and does not cease until it has extended into the socket, and destroyed altogether the connexions of the teeth, which become loosened and fall out, after which the gum will heal. There is a mild variety of stomatitis, which may be denominated catarrhal, attended with a copious secretion of mucus and saliva, with a furred tongue, and deficient taste, but with little redness, swelling, or pain. This is sometimes mistaken for disease of the stomach, especially when it becomes chronic; but may be distinguished by the undiminished powers of digestion, and the absence of direct gastric symptoms. Upon careful observation, it will be found that the discharged liquid pro

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