RHEUMATISM-TREATMENT OF ITS COMPLICATIONS.

applied on or near to the affected joints. In
this form of the disease, a full dose of calomel,
colchicum, and opium, taken at night, and a
draught with castor oil and spirit of turpentine
the following morning, in addition to these
means, and repeated at intervals of one, two,
or three days, will generally be of great service.
I have seen the tinctura lyttæ and capsicum
given with the medicines now mentioned until
some degree of irritation was produced in the
urinary organs by the former, and until heat
or smarting at the anus followed the latter,
prove most beneficial in this form of the com-
plaint. If the affection of the joints become
chronic, the internal use of the iodides, and the
repeated application of blisters, or the forma-
tion of issues near the joints, and recourse to
thermal springs, are among the most efficacious
If this form of the disease be
means of cure.
neglected at an early stage and becomes chron-
ic, it is not only removed with the greatest dife
ficulty, but organic lesion of the joint is very
apt to supervene.

164. G. Rheumatism is often associated with
influenza or catarrhal fever, or with ague, or with
a remittent form of fever, and I have already
shown that the complication is due chiefly to
the presence of malaria in the humid and cold
air to which the patient has been exposed, or to
his having previously been the subject of ague
(58). In cases of either of these associations
the treatment which I have recommended for
the rheumatic affection is equally appropriate
to the associated disorder, the lowering means
too frequently prescribed for the former aggra-
vating not only it, but also the complication,
and favouring the supervention of still more se-
rious internal disease, especially of the fibro-
serous or serous surfaces.

66

[There is a rheumatic affection not infrequently met with, which may be termed hepatic, in which we find pains in the back, shoulders, breast, and superior extremities, and even of the larger joints, as mentioned by Sir W. PHILIP. Dr. JAMES FOUNTAIN, a distinguished practitioner of West Chester county, New York, called attention to this complication in an article on "Diseases of Irritation," published in the New York Medical and Physical Journal in 1826. Dr. FOUNTAIN describes these pains as the effect of nervous irritations, symptomatic of the internal hepatic affection, and states that he has known people labouring under slight hepatic derangements, who for years have seldom been free enjoy a de"Some," he remarks, from these pains wandering from one joint to another. gree of health, while others are feverish. Like sub-acute hepatitis, these pseudo-rheumatic pains may exist an indefinite length of time without inducing organic derangement. But where, from any cause, they become aggravated, a real inflammation is developed, and from Instead of an an effect they become a cause. irritative symptomatic, we have now an inflammatory affection to encounter, frequently involving in the excitement the whole vascular system, producing a symptomatic fever. The former pains are supplanted, and a new feature is given to the primary disorder of the joints; and on the principle of counter-irritation the original hepatic disease is sometimes wholly removed. Now it must be evident that this complication, from beginning to end, must be totally different from ordinary rheumatism from cold. This form is quite common; and the ill success of the means ordinarily employed has contributed not a little to strengthen the prejudices of people against the use of medicines in that disease." Dr. FOUNTAIN divides the means of cure in hepatic rheumatism into two classes, those required during the irritative, and those during the inflammatory stage. During the irritative stage, the indication is, of course, to remove the exciting cause-the hepatic derangement. For this purpose he recommends mercurials and laxative medicines. Four or five grains of blue pill, with the same quantity of rhubarb, should be administered twice every day, and as much sulphur, magnesia, and senna as will open the bowels fully, is to be given every second morning. After using these remedies for a week or ten days, an infusion of quassia or colombo may be taken every morning, using at the same time some moderately stimulating embrocation to the painful parts. During the second or inflammatory stage we have heModerate venepatic derangement, universal debility, and local

165. H. If Pneumonia or pleuro-pneumonia
supervene in the course of acute rheumatism,
a moderate general or local vascular depletion
will be prescribed with advantage, if the pa-
tient be strong or plethoric; and calomel or
antimonials with opium, and saline diaphoret-
ics, will generally be required. Blisters will
In a case which was under
also be of service.
my care, caused by removal in an unfavourable
state of weather and season into a damp house,
rheumatism, in a sub-acute form, disappeared
from the arm after two doses of the wine of
colchicum, of ten drops each, had been taken,
and was immediately followed by asthenic pneu-
monia with rusty expectoration. A small cup-
ping on the chest (seven ounces), and camphor
with ammonia, small doses of the decoction of
senega and terebinthinate rubefacients, and due
attention to the several secretions and excre-
tions, especially to those from the skin and kid-inflammation to encounter.
neys, were soon followed by recovery. Pneu-
monia and pleuro-pneumonia associated with,
or consequent upon rheumatism, have but rare-
ly come under my observation; and the asso-
ciation of scurvy with rheumatism is not more
frequent, although these complications appear
to have been of more common occurrence dur-
ing the early part of the last century, according
to the best practical writers on medicine in that
period. More recently, lemon-juice, which has
been found so beneficial for the prevention and
cure of scurvy, has been said to have been serv-
iceable in rheumatisın, but I have had no expe-
rience of it in this latter complaint.

section is here recommended by Dr. FOUNTAIN,
for he thinks that rigorous depletory measures
are unsafe, in which opinion we agree with
him. The bleeding is to be aided by the ad-
ministration of ten or twelve grains of a pow-
der consisting of one part of calomel, two of
antimonial powder, and four of nitrate of pot-
ash, every three hours from mid-day till nine in
the evening, followed next morning by an op-
Dr. MOORE, in his New York
erative dose of sulphate of magnesia and infu-
sion of senna.
Hospital Report, has noticed the same hepatic
complication, and derived much benefit from
the cathartic plan. The whole body, and the

en as soon as the patient is able, so as to preserve a free excretion from the skin. If any cardiac affection is present, an issue should be kept freely discharging near the margins of the ribs. In more chronic or mild cases, the regimen and diet ought to be regulated according to the peculiarities of individual cases; but, in every instance, change of air, active exercise in the open air, when it can be taken without detriment to the affected part, flannel clothing nearest to the skin, a diet regulated conformably with the state of the complaint, and due regulation and promotion of the several secretions and excretions, are most important aids to a permanent recovery, and to the prevention of a future attack.

oints especially, are to be carefully enveloped months, from which the patient has not yet enin flannel. tirely recovered, nor does he enjoy as much exThe Phosphate of Ammonia is strongly rec-emption from suffering as before subjection to ommended in rheumatism by Dr. T. H. BUCK- the water cure. Such cases are by no means LER, of Baltimore, under the belief that it tends of rare occurrence, while in other instances to eliminate uric acid from the blood, by form- great benefit has resulted from this powerful ing with it a soluble urate of ammonia, the phos- alterative treatment.] phoric acid being neutralized by the soda with 166. vii. REGIMEN, Diet, and CHANGE OF AIR. which the uric acid may be combined in the -There are few diseases which require greatblood. Dose ten to twenty grains, from three er attention to these than rheumatism. Durto six times in twenty-four hours, in all forms ing an attack of the acute form of the disease, of rheumatism. (American Journ. of Med. Science, the regimen and diet should be antiphlogistic. N. S., vol. xi., p. 108.) Dr. RUSCHENBERGER, of Such articles as are the least likely to occasion the United States Navy, has derived much acidity should alone be taken. Saccharine subbenefit in this disease from cold water dressings stances ought to be avoided. As soon as conto the joints, and the use of from three to six valescence has proceeded sufficiently far to adgrains of opium at night, with an equal quanti-mit of removal, change of air should be recomty of sulph. quinine. (American Journal of Med-mended, more particularly to a warm and dry ical Science, N. S., vol. xiv., p. 263.) Professor air, or to a place where warm salt-water baths WOOD, of Philadelphia (A Treatise on the Prac- may be procured, or thermal springs may be tice of Medicine, 2d ed., vol. i., p. 435), speaks used, especially to Bath or Buxton. If the atfavourably of bleeding once or twice in acute tack has not been complicated with, or followrheumatism, followed by active purging with ed by, any affection of the heart, regular and salts, jalap, and bit. potassa, calomel, or colchi-active exercise in the open air ought to be takcum and magnesia, with refrigerant diaphoretics, as a combination of tartar emetic and nitre, from one twelfth to one sixth of a grain of the former and five to ten grains of the latter in water, at intervals of one, two, or three hours; or nitrate of potash in the form of an effervesIcing mixture, and the occasional use of the warm bath. Pain is to be alleviated and sleep procured by full doses of DOVER's powder at night. If the powder be rather feeble, pulverized guaiacum, in doses of ten to twenty grains, is to be combined with the DOVER's powder. Should the disease not yield to these measures in ten days or two weeks, then calomel is recommended, with a view to its alterative influence, but not previous to a decided reduction of the general excitement. It is seldem necessary to carry it to the point of salivation. At this period, also, Professor WOOD thinks the colchicum most beneficial with one of the salts of morphia, and it may be given before or in aid of the mercurial. If an adynamic condition of the system supervene, then the sulphate of quinia, in doses of one grain every hour, is strongly recommended as highly beneficial. If the heart or brain become seriously involved, venesection is to be carried as far as it can be borne with leeches or cups, succeeded by a large blister, while calomel is pushed to speedy salivation, and attempts are made, by sinapisms, &c., to invite the disease back to its original seats. In chronic rheumatism, Professor WooD recommends mercurial alteratives as by far the most successful remedies, often carried so far as to induce ptyalism. The attention of the profession in this country was first strongly called to this mode of treatment by the late Dr. OTTO, of Philadelphia (see Eclectic Repertory, vol. ix., p. 528). Dr. CHAPMAN speaks strongly of savine as a remedy in chronic rheumatism; others have found great benefit from cimicifuga, phytolacca, and the xanthoxylum or prickly ash. That a course of hydropathic treatment often breaks up the disease no one will deny, although it is not unattended with danger. In one instance we knew it bring on universal and severe inflammation in all the joints of the body, attended with long-protracted confinement to bed, and total inability of motion for several

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Prag., 1817.-Zollic oil); vol. v., p. 248; vol. vii., p. 146; vol. viii., p. 523; vol. koffer, On the Sanguinaria Canadensis in Acute Rheuma. ix., p. 205; vol. x., p. 18, 355, 437; vol. xii., p. 168; vol tism, in Philadelphia Journal of Medical Sciences, vol. vi., xiii., p. 251; vol. xiv., p. 343; vol. xv., p. 14; vol. xvi., p. p. 295.-W. Balfour, Illustrations of the Power of Com- 374, 578; vol. xix., p. 399; vol. xxviii., p. 395.-The Medpression and Percussion in the Cure of Rheumatism, 8vo. ico-Chirurgical Review, vol. xxix., p. 657 —Ibid., April,

63;

son's treatise appeared in 1650; and hence it may be inferred that the complaint at first appeared at a much earlier period. FLOYER, indeed, states that " Rickets first appeared in England about the year 1620." These, as well as other contemporary writers, contend that the disease was considered of recent date; that it first appeared in the southern and western parts of the island, and that it had spread to the eastern and northern counties by the time when GLISSON wrote.* Softening of the bones, although most frequently observed in the young of the human species, is not confined to the species; for it has been observed in monkeys, in the several domestic animals, in the ox, the horse, and in pigs; and even in poultry, especially when exposed to cold, humidity, unwholesome air, and to improper diet. [It has also been observed in the bear, the dog, calves, lambs, the cat, rat, mule, lion, and the porcupine.] Viewing rickets as consisting chiefly of an imperfect assimilation, in which the bones suffer more especially, and evince more or less softening, I shall first and chiefly consider it as it appears in children, as common or true rickets; and next, very briefly as it occurs in adults, or as the mollities ossium of writers.

1838, p. 538.-Ibid., July, 1836, p. 82, p. 252. Ibid., Octo- |
ber, 1836, p. 341.-Ibid., April, 1837, p. 511.-London Med-
ical Gazette, 23d Jan., 1836; 21st October, 1837, p. 117.-
Seymour, in ibid., 22d October, 1836; 29th October, 1836;
No. 464, p. 119; No. 469, p. 310; No. 474, p. 510.-Lancet,
No. 601, p. 820; No. 607, p. 72; 25th June, 1836, p. 444; 23d
July, 1836, p. 572; No. 675, p. 634; 1st October, 1836, p. 61.
(Gonorrhaal.)-The British and Foreign Medical Review.
Ouo, in vol. ii., p. 252.-Brera's Pathology of, vol. i., p. 566.
-Bene, vol. i., p. 7.-Malcolmson, vol. v., p. 130.-Piorry,
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184, 268; xxi., p. 372; xxii., p. 427; xxiii., p. 126.
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latina."]
RICKETS. SYNON.-Rhachitis (from paxis, the
spine, or paxirns, spinal), Glisson. Rachitis,
Suavages, Vogel, Boerhaave, Cullen. Tabes
Pituitosa, Morbus Anglicus, Osteomalacia, Mol-
lities ossium, Osteosarcosis, Auct. Innutritio
ossium, Darwin. Osteomalakia, Swediaur.
Scrofula rhachitis, Young. Cyrtosis rhachia,
Good. Tabes pectorea, Spina nodosa, Rachitis-
mus; Rachite, Rachitisme, Riquets, Fr. En-
glische krankheit, Germ. Rachitide, Ital.
Rickets, softening of the bones.

3. I. RICKETS AS AFFECTING INFANTS AND CHILDREN.-Rickets have been observed in the fœtus by several writers; but it is doubtful whether or not the imperfect ossification, and consequently softened state of the bones, observed congenitally, should be viewed as rickets, as in this disease there is, as will be shown hereafter, a change in the state of the affected bones different from a mere delay or simple imperfection of osseous formation. The complaint has been met with from the earliest months until approaching puberty; but it is most commonly observed to commence during the first dentition, or from six or seven months to three years of age. M. GUERIN States that, of 346 cases, 209 were affected from the age of one to three years. Three cases only were congenital, and 34 only occurred from four to twelve years. Of the 346 cases, 148 were males, and 198 females.

4. i. DESCRIPTION.-The course of the disease has been divided by MM. GUÉRIN and GUERSENT into three stages, 1st, that of incubation; 2d, that of deformity; and 3d, that of restoration or of irremediable atrophy, as the termination may be. From considerable experience of the complaint, I believe the division to be useful, and to be based on sound observation.-A. The precursory or incubative period does not constitute the complaint; but consists chiefly of that impaired state of the organic nervous or vital functions which occasions those changes constituting the malady; and that state

CLASSIF.-Class 3d. Cachectic diseases; Order 2d. Swellings (Cullen).-Class 5th. Diseases of the Excernent Function.Order 1st. Affecting the Parenchyma (Good). IV. CLASS, IV. ORDER (Author). 1. DEFIN.-Softening and curvature especially of the long bones, and swelling of their extremities; the head being large, the spine bent, the abdomen enlarged, the flesh emaciated and flabby, with all the signs of general debility and impaired assimilation. 2. This disease was first described by Dr. DAVID WHISTLER, in his inaugural dissertation (De Morbo Puerili Anglorum dicto" the Rickets." Lugdun. Batav., 1645.) GLISSON, who soon afterward wrote on this complaint, states that he was induced to give it the name of Rhachitis, because the spine was so often affected in its course, and because the term nearly resembled rickets, the name by which it was commonly known in England before the time at which he wrote. Dr. CUMMIN remarks that the works of WHISTLER, GLISSON, BATE, and others procured a currency for their opinion that the disease made its first appearance in the western parts of England towards the middle of the seventeenth century, and that it hence was called the English malady. The first of these writers published in 1645; the second edition of GLIS-lief.]

ted in England, or that it is a new complaint. The kinds * [There is no proof whatever that this disease originaof deformity which it produces are described by both Grecian and Roman authors as existing in ancient times. It was not until the seventeenth century that the disease fections which occasioned deformity of the limbs: there was distinguished by any particular name from other af is no doubt whatever that it has existed in all ages, espe cially in cold, variable, and humid climates, like that of Great Britain. We have records of its very extensive by Dr. COPLAND, and also of the great mortality which it prevalence in England long before the period mentioned occasioned. We know that some of the English medical historians represent it as having originated in Dorsetshire and Somersetshire, and from these counties to have spread over the world; but there is no foundation for such a be

may be associated with a variety of ailments of the digestive and assimilating organs. The transition from apparent health to the incipient state of the disease is always gradual, and consequently more or less slow; but it may be masked by some other disorder, and hence not be recognised until this period has made considerable progress. The impairment of vital power originating the malady is most frequently associated with indigestion, or with chronic irritation of the gastro-intestinal mucous surface, or with bronchitis, or with hooping-cough, or even with lobular pneumonia, and with more or less change of the urine, which, however, has generally been imperfectly examined. Nevertheless, cases occur in which but little or no ailment, or merely slight debility of the digestive and assimilating functions, has been remarked up to the time of the manifest appearance of the complaint.

7. B. The second period is that which is characterized by more or less deformity of the bones. The extremities of the long bones, especially those of the ankles and wrists, and the sternal ends of the ribs, are the parts which first evince this stage, by their swollen or knobby appearance; and the lower portions of these bones now begin to yield, especially those of the lower limbs, when the child is so old as to attempt to walk. The increasing softness and yielding of the bones are now apparent in the gradual change of their forms. The lower extremities are usually curved by the weight of the body, while their bones yield more or less to the action of the most powerful of the muscles. They generally present the convexity of the curvature outward, and the concavity inward. The femurs are sometimes curved forward, but more frequently outward, as are the tibiæ. The knees are sometimes bent inward, and the feet thrown 5. With the approach of rickets, the child is outward, so that the knees press against each dull, or sad, or peevish; is averse from play or other, and the patient rests on the inside of the any action; prefers to sit or lie, appears feeble foot; and as often the knees are separated to or indolent, or complains of inability to use ex- an unnatural distance by the continued curvaertion, and of pains in the joints and along the ture outward of both the thighs and legs, the bones; the appetite is impaired or is capricious; whole of the lower extremities forming irreguthe bowels are irregular or relaxed, and the lar curvatures, with the convexities outward stools morbid, or pale, or deficient in healthy and greatest at or near the knees. In some bile; the face is pale, and the flesh becomes cases the angle formed between the neck and soft and flabby; perspiration is free on slight shaft of the femur is changed from an obtuse exertion, and is weakening and colliquative dur- to a right or an acute angle. Much of the deing sleep, and the skin often moist during the formity which takes place in this stage is owing day. The pulse is quick, soft, and broad or open, either to the manner of carrying or placing the the external veins are large, and the jugular child, or to the weight of the body and head veins much dilated. Thirst is generally pres-upon the lower extremities when attempts are ent; emaciation becomes evident, and the ab- made to stand or walk, and upon the upper exdomen tumid. With all these symptoms, how-tremities also, when the child crawls about on ever, no evidence of rickets may exist; for they may accompany or usher in other maladies; 8. The head of the rickety child is generally but when with these the urine is more abund- unusually large. The vertex is often flattened; ant than in health, and when it deposites a co- the forehead is prominent and broad; and the pious calcareous sediment, or abounds in the centres of the parietal bones expanded. The phosphates, then the early or precursory stage fontanelle is wide and unclosed; and, if the of the complaint may be considered as already child be very young, the sutures expand or represent; and it is in this stage especially that main open. The bones of the face are imperthe salts are most abundant in the urine (16). fectly developed, or are partially arrested in 6. The duration of this period necessarily va- their growth; and the under-jaw is often elonries with the number and severity of the symp- gated. The process of dentition is arrested or toms now enumerated, with the age and consti- delayed; or, if they have been formed, they soon tution of the patient, and more particularly with decay, owing to softening of the fangs, and of the quantity of phosphates contained in the the alveolar processes. The clavicles are, after urine. It may thus vary from one or two the bones of the lower extremities, the most months to six or seven; but when the head is frequently deformed. The long bones of the very large, and the bones of the head imper-upper extremities are much less frequently fectly developed, or the sutures not closed, when the abdomen is very tumid, the bowels lax, the stools pale and deficient in bile, and the urine abundant, the second or developed state of the complaint appears early. The continued operation of the causes, neglect or injudicious treatment, and the occurrence of some local intercurrent affection, may shorten this period; while a proper treatment and regimen may remove all the symptoms, and prevent the development of the disease. In some cases, also, the precursory stage may be hardly apparent, the first indication of the complaint being the actual deformity of the limbs constituting the second stage; the child may have appeared, up to the detection of the flexure of the long bones, in good health; although closer observation and an examination of the urine would have detected more or less evidence of disorder.

its knees and hands.

curved than those of the lower. The spine is generally also curved, owing as much to yielding of the ligaments as to softening of the bodies of the vertebræ. The curvature is commonly outward, but it is sometimes also lateraloutward in the back or between the shoulders, where the curvature is also to one side, and to the opposite side in the lumbar region, where also there is sometimes a curvature inward The curvatures of the spine, especially outward, are generally connected with a flattening of the ribs laterally. The ribs are turned inward, and their sternal extremities, at their connections with their cartilages, are swollen into knobs. While the sides of the chest are thus compressed, the dorsal spine is pushed outward, and the sternum also outward, the diameter of the chest, from right to left, being thus much diminished, and the "pigeon breast" formed. (See art.