rheumatic, and these have left the joint tissues thickened; the part is therefore more or less stiff; it may otherwise be painless or may be the seat of nightly vague pains. Now, our aim is to produce absorption of this thickening, and so to modify the constitutional taint; that he shall not have returns of the active stages. Among the alterative remedies, the four following are chiefly available.

Mercury, and its use in the subacute condition, has been considered; a slower and more alterative mode of giving that medicine may be employed, if it have not been pushed or used at all in the more rapid stages; but here also the power of employing it locally must not be sacrificed by too zealous desire of administering it by the mouth.

Iodide of potass has already been mentioned; its control over inflammations of fibrous tissues renders it of undoubted value in rheumatic disease. It is more valuable in very chronic disturbances than in the more acute; indeed, when fever is present, it should be avoided, as it not unfrequently increases this action. There are few medicines of whose modus operandi we know less than we do of this, and perhaps every one who tries to think out the matter may have a different theory on the subject. My own idea is, that it gives a quality to the fluids of the body which tends to check cell generation; hence its very decided effect upon all connective and fibrous tissues-hence its capability of producing absorption and ultimate marasmus. This notion, however, is offered as a conjecture simply. A teacher at one of the large metropolitan schools once said to a student who asked about the action of this remedy, "Well, sir, it is difficult to define; but it is a very excellent medicine when you don't quite know what is the matter with your patient." To such a doctrine it is hardly necessary that we should subscribe, but it has this amount of truth, that the salt in medicinal doses does no harm, which has yet been pointed out; although it may be that some one will by-and-bye trace all the misfortunes of the world to this medicine -as has already been the fate of vaccination and salt. For rheumatic disease, the remedy may be advantageously given in sarsaparilla, or taraxacum, or the scoparium.

Alkalis, or rather alkaline carbonates, in small quantities, are of very considerable value. A dose about an hour or two after each

meal in some aromatic water, or in a state of effervescence, will have marked effect, not merely upon the distension and flatulence, which so often accompanies the chronic rheumatic state, but also upon the more distant symptoms. It may be permissible to call attention to the detrimental action of tea, and, to a less degree, of coffee; to the great injury often produced by ale or porter, particularly of those sorts that contain any considerable amount of saccharine; and the desirability even that the wines which may be substituted for malt liquors should be of that quality which is called dry, but which nevertheless contain as small a quantity as possible of acids-the tartaric and mallic.

The other class of remedies, the diaphoretics, consists chiefly of opium with ipecacuanha, guaiacum, and James's powder; the former will be found useful when there is much pain at night, an irritative condition, with good performance of all secretions, except that of the skin; but chiefly may the Dover's powder be prescribed while the patient is taking some medicine of the alterative class.

Guaiacum is most availing in the atonic form of rheumatism, and therefore, from what has been said above, when the more acute stage has been treated with colchicum.

James's powder is most useful when actual feverishness, not mere irritation, comes on at night, and when the patient is strong and his appetite good.

A mid place between these two classes of remedies is held by certain natural springs, both for bathing and drinking-Buxton and Bath for instance. Some of the continental baths, as those of Aix and Wiesbaden, have an advantage over ours, not merely in the quality of the water, but in the careful arrangements and adaptation to each case, in the mode of bathing, drinking, &c.

I do not, however, imagine that the particular locality, metallic, or earthy solution, is a necessary part of these bathing arrangements, although there is no doubt that change of scene and air, regular habits, &c., conduce to the cure. The various forms of bath, such as may be obtained in any good establishment, are extremely beneficial. The Turkish, hot air, and vapour, are valuable, and in cases where either expense or moving is to be avoided, the lamp bath, which is very easily arranged, may be employed with the greatest advantage. The object

aimed at is to procure a large amount of transpiration, and the method is apparently immaterial. The Turkish and lamp bath are the most powerful; next the hot air;* then the vapour bath, and lastly mere hot water.

LOCAL TREATMENT.-When the subacute inflammation, of whose treatment we have already spoken, has subsided, there will be left behind either chronic inflammation or simply thickening. The former we must of course try to subdue, since, continuing, it destroys the joint. The latter we should endeavour to get absorbed, not only because it produces a certain amount of difficulty in walking, but also because it gives the next inflammation, whenever, and if ever, it may take place, a certain vantage-ground, increasing the difficulty and diminishing the effect of treatment. The inflammatory condition will compel rest in that posture for each joint, which has been described as its proper position; blisters, not immediately over but at some distance from the synovial membrane, are much more valuable than in the strumous form, and if it be intended to give mercury by the skin, blue ointment may be applied to the raw surface; but care must be taken that this surface be not too extended. In these cases, setons or issues, near the joint, are often beneficial; it appears as though the production of a suppurative condition in the neighbourhood of the fibre-producing action checked the tendency to thickening. Local heat is very advantageous, particularly as it can be so managed as to produce local transpiration, a method of securing which is described further on.

As the inflammation yields, our efforts are to be directed to procuring absorption. If there be at the special points of pain no tenderness, it is not necessary to keep the limb in absolute immobility, although rest must be enforced if the patient's circumstances in any way admit. A powerful absorbent remedy is to keep the joint wrapped in linen, covered with mercurial ointment, due regard being paid to its systemic action and to the patient's general condition, for if the health be feeble, or if mercury have already affected the system, this method cannot be employed. Iodide of potass ointment rubbed in gently night and morning, and spread on lint wrapped round the joint, is also valuable; and equal parts of this, and of the mercurial ointment, *The hot air and the lamp-bath may be arranged in bed.

is a very powerful absorbent. Flying blisters, used only as strong rubefacients, not as vesicatories, increase the power of those ointments. Transpiration, produced by fitting to the joint a loose india-rubber sock, kept close at each end by bands of the same substance, and allowing steam to pass in from a kettle or boiler through a tube, has been productive of considerable benefit. When there is absolutely no inflammation whatever, and absorption begins to act, evidenced by decrease in size, gentle shampooing is to be employed, together with passive motion and other manipulations.

It is to be remembered that no local treatment will be of much avail as long as the systemic condition lasts, for unless the force of the rheumatic diathesis be diminished the inflammation cannot be entirely subdued, and we may not only expect a return of the more acute phase in the way that has been already described, but also a continual course of deterioration in the articular and periarticular tissues. Many persons, who may have recovered from an attack of acute rheumatism, with a sound heart, will subsequently gradually acquire a disease of that organ whose source is undoubtedly rheumatic; and in a similar or rather identical manner a joint will gradually be destroyed by an inflammation of the same character, unless the surgeon will treat the general as well as the local disease.

CASES OF THIS DISEASE.

CASE XXXVI.-Thomas Gwillim, gardener, aged 49, came from Monmouth to be admitted into the Charing-Cross Hospital, under Mr. Canton's care, November 29th, 1858.

History.-About two years ago he sprained the right knee while lifting a heavy wheelbarrow; the joint was very painful, but he kept at his work two days, and then the knee swelled very much and he became unable to walk; but, after fomentations and rest, it got so far better that he was able to resume his occupation. About a fortnight or three weeks afterwards he, one evening, was very tired after work, lay down on the ground and fell asleep; when he awoke it was late night or early morning, and he set off on his walk home (two and a half miles), but before he got there his knee became so painful that he could hardly get on. The next day he could not use the limb at all; the joint was much swollen and he sought the advice of a surgeon, who applied leeches and poultices, without procuring much relief; he then became a patient at the Monmouth Dispensary; subsequently sought the advice of an old woman who gave him something that took the skin off his knee and made him worse.

From that time the joint has continued to increase in size; till of late he was able, with great pain, to work for about two hours most days in the week; often, "when walking right well, his knee seemed to be catched and held tight and to be wonderfully full of pain;" on account of these occurrences he has always, when at work or walking, bound a handkerchief as tight as he could round the knee. During the last year, particularly, the joint has swelled, and he is unable to bear any weight upon it. The knee is a good deal enlarged, but cannot be measured against the other, as, on account of an old accident, there is deformity also of the left. The diseased joint has lost the usual outline and has a square look; the line of the ligamentum patella is concealed, and on each side of it there is, instead of the usual fossa, a hard, semi-elastic, non-fluctuating swelling; a similar enlargement is particularly well marked above the patella, where there is a hard lump; there is much thickening under the skin, which is bound down to the parts beneath, and which prevents the different anatomical points from being made out so clearly as they should be; there is some grating when one bone is moved on the other, this causes slight pain; the two surfaces may be pressed together by striking on the heel or other means without producing the slightest pain. He complains much of the limb jumping with severe pain just as he is going to sleep, and so bad is this that often he is afraid to sleep.

The limb was placed on a splint; issues, blisters, &c., as local means, with different forms of tonics were employed. He also underwent some treatment by the assistant physician, Dr. Hyde Salter, for chronic bronchitis, and was benefited. The knee, however, only got more painful and his health more feeble; the limb, too, started more and more, so that he hardly got any sleep at night. About the middle of January the joint swelled more and soon became fluctuating inside the patella, without, however, losing its square form; and, on the

26th Jan., Mr. Canton punctured the joint with a trocar and canula where the skin seemed thinnest, just inside the patella; so little pus escaped that a second opening was made; yet, altogether, not more than a drachm, or a drachm and a half, of a very thin opalescent fluid came

away.

12th Feb. He was in no wise relieved by the evacuation of so small a quantity of fluid, and as his health seemed giving way under the pain and sleeplessness produced by the disease, it was proposed to him that the limb should be removed, and this day the operation was performed.

Examination of the Limb.-On opening the joint a quantity of very thin pus escaped, with curdy flocculi therein; the synovial tissues were much thickened by false membrane, whose cut edge had a stratified appearance, and was in rounded waves separated by deep wrinkles, which were most marked around the patella and its ligament, and thence ran backward becoming shallower as they went; the interarticular menisci had disappeared, but were, in part, replaced by false tissue, which, however, was both thinner and less broad than those structures. In no part did the membrane adhere to the cartilage. Thickening was produced not only by this fibrous formation on the inside of the synovial membrane but also by consolidation of the tissues around it; a faint line, which, however, was in parts obliterated, ran round the joint in this mass of new tissue,