ceeds best is opium, or some other anodyne applied more immediately to the seat of the disorder. For this purpose, a glyster, consisting of 2 or 3 ounces of thin starch, and from 20 to 30 minims of laudanum, or, what is perhaps better, as being less liable to be rejected, a suppository, consisting of from 1 to 2 grains of opium, and 3 or 4 of the extract of conium, or extract of hyoscyamus, may be applied morning and evening, taking care, either by means of gentle laxatives or mild glysters, to counteract the constipation such a practice is likely to occasion. If by these applications we can succeed in enabling the patient to desist from repeated straining, we shall for the most part have the satisfaction to observe the disease subside with comparative rapidity; and even if it depend upon an immovable cause, that the distress of the patient will at least be greatly alleviated. When the disease has been suspected to be attended with ulceration of the mucous membrane, and especially when connected with calculus, the occasional injection of a tepid mucilaginous fluid into the bladder has sometimes afforded temporary relief to the patient. Such applications, however, if admissible at all, require great circumspection. The last indication, is to remove any remaining irritation of the mucous lining of the urinary passages generally. This part of the treatment is applicable to the more advanced stage of the acute, and to almost every stage of the chronic, forms of the disorder. Not the least important means of effecting this is, by so regulating the diet and regimen of the patient as to secure a healthy digestion and assimilation, and the consequent secretion of healthy urine. As medicines, the decoct. uvæ ursi, the infus. pareira, and infus. diosma, will be found amongst the most useful; either of which may be given with an acid or an alkali, accordingly as an alkaline or acid condition of the urine shall be found to indicate.

RHEUMATISM.

Rheumatism is a name under which, in modern times, several forms of disease have been included; diseases which, although they have some symptoms in common, and are occasionally observed to pass into each other, differ nevertheless in many respects, both as regards their general character and progress, and their respective modes of treatment.

Rheumatism was very imperfectly distinguished by the ancients, who appear to have treated of it, in common with gout, under the general name of arthritis, employing at the same time, certain subordinate terms, to express the varieties of the disorder depending upon the particular part of the body affected. Subsequent writers designated rheumatism arthritis vaga, from its being more liable to change its seat than gout. Ballonius appears to have been the first, accurately to discriminate and describe the disorder, and gave to it the name of rheumatism. In this country it was very imperfectly known till the time of Sydenham, who, about the year 1670, published a very accurate description of it. More recently, rheumatism has been very commonly divided into the acute and chronic; the former being distinguished by the presence of a considerable degree of febrile action, together with acute inflammation in the parts affected; whilst in the latter, the febrile action and symptoms of local inflammation, are either slight or altogether absent. Nevertheless, in modern, as in ancient times, divers names have been bestowed upon individual forms of rheumatism, according to the particular part affected; but inasmuch as almost every muscular, tendinous, and ligamentous structure of the body appears to be susceptible of rheumatic disease, such sub-divisions would be endless, and could not fail to prove

exceedingly embarrassing to the student. For practical purposes, therefore, it will perhaps be most convenient to consider the ordinary varieties of rheumatism under the three following heads:-1st. rheumatitis, acute rheumatism or rheumatic fever; 2. rheumatagra, subacute rheumatism or rheumatic gout; 3. rheumatalgia, arthrodynia, or the purely chronic rheumatism of authors.

RHEUMATITIS, ACUTE RHEUMATISM OR RHEUMATIC FEVER.

Rheumatitis usually commences, like the phlegmasiæ, with a sense of lassitude and rigors, succeeded by heat, thirst, anxiety, and restlessness; which symptoms are soon followed by severe pains affecting different parts of the body, but chiefly attacking the larger joints, as the shoulders, elbows, wrists, knees, and ankles. These pains are extremely tensive and pungent, they are observed to follow the course of the muscles, and the parts are so acutely sensible, that the slightest touch or motion causes the patient to cry out. The pain is generally succeeded in a short time by some degree of swelling and redness of the affected joints, the swelling being very commonly attended with some slight mitigation of the pain for a time; nevertheless, both the pains and the febrile symptoms pretty uniformly suffer an aggravation towards night. The pains are by no means confined in every instance to the joints; they may take place in almost any muscular, tendinous, or ligamentous structure of the body; they sometimes attack with great violence the muscles of the back and loins; those of the abdomen or ribs; and more rarely the diaphragm: the pains in the back, loins, ribs, and abdomen, are chiefly felt on any attempt being made to move; whereas, when the diaphragm is affected, the pain is more or

less constant, is exceedingly aggravated by the act of breathing, and is chiefly complained of at the scrobiculus cordis, shooting through towards the spine. So long as the febrile excitement continues severe, the inflammation is liable to quit one joint and attack another; and again, perhaps, to leave that and return to the joint originally affected. This tendency to shift its seat at an early period of the complaint, forms a striking feature of acute rheumatism, and serves in some measure to distinguish it from gout, to which it is very closely allied, but which, in a large majority of cases, continues fixed in the joint originally attacked. At this early stage of the disorder, the pulse is usually full, hard, and frequent, with great heat and dryness of the skin; for although profuse sweats do not unfrequently break out during the first few days, they are generally observed to be extremely partial, and to produce no sensible relief whatever to the patient's sufferings. Notwithstanding the high febrile action present, the functions of the brain are very rarely disordered, even in a slight degree, and the countenance is for the most part rather pale than flushed, and in consequence of the presence of a clammy perspiration, often presents a peculiar shining or greasy aspect; the tongue is white and furred, but generally moist, the moist white fur usually communicating to the surface of the organ a very characteristic creamy appearance; the urine at the commencement is commonly pale, it afterwards becomes highcoloured, and on the subsidence of the fever deposits a lateritious sediment.

It has already been observed, that the fever and the pain generally suffer an exacerbation towards evening; the fever, however, often remits, and occasionally subsides and goes off altogether, without the patient experiencing any material relief from pain: indeed the fever and the pain

do not appear to bear any very essential relation to each other; for although it be true, that if by a bold and active depletion we succeed in cutting short the disease, the fever and pain will occasionally both subside and disappear, yet this is by no means the case in every instance; we may subdue or remove the fever almost entirely, whilst the pains in the joints shall continue but little abated.

The disease may be protracted for one, two, or three weeks, or even longer, with more or less fever; and may then disappear altogether; or it may pass into one of the less acute forms of rheumatism to be noticed hereafter.

Terminations.-Acute rheumatism may, and usually does, terminate in resolution. It constitutes a striking peculiarity of ordinary rheumatic inflammation, that it never terminates either in suppuration or gangrene. It has occasionally appeared to give rise to suppuration in the neighbouring cellular tissue, but even this is of extremely rare occurrence; neither does it terminate in adhesion properly so called. A very common effect of rheumatitis, is a copious effusion of synovial fluid into the capsules of the affected joints, or into the sheaths of the tendons and bursæ mucosæ involved in the disorder: it is a sequel attended with little inconvenience and no danger; it will in general gradually disappear spontaneously, and if not, its removal may be materially promoted by art. There is, however, one effect of rheumatitis, which is but too frequently witnessed, and which calls for more particular attention; that is, a metastasis, as it has been injudiciously called, to an internal organ, by which that organ becomes affected with acute inflammation. This reputed metastasis often takes place without the inflammation quitting the joint or joints primarily affected, constituting apparently a mere part and parcel of a general rheumatic disease, and when consequently it cannot properly be regarded as a metastasis: in