This is a book published in 1850 in London about FRORIEP’s work on the “Therapeutic Application of Electro-magnetism in the Treatment of Rheumatic and Paralytic Affections”. It is a translation from the original German book published in 1843. It is translated by Richard Moore Lawrence. Once I read his original work, I realized he is clearly talking about painful spots or nodules in the so-called “cellular tissue” by what he called “rheumatic effusion”. We could say he is talking about “mice” in many locations.

Has Froriep’s work been misunderstood?

Froriep’s concept of “Muskelschwiele” or “muscle callous” is now mentioned in many resources since he is one of the first authors to have talked about the concept of trigger points or fibromyalgia.

To be honest, everybody now can read Froriep’s original work or his English translation. After reading myself Froriep’s work I can certainly say that Froriep’s concept of “Muskelschwiele” is far from the current conception of “trigger point” and has been somehow misunderstood. In the following text I will argue my statement, but first of all, here are the links to free access Froriep’s and Moore-Lawrence’s work:

Free on line access from the translated book in English (1850):

//archive.org/details/ontherapeuticapp00fror/page/n9

Original book from Froriep 1843 in old German (a bit difficult to read) free on line:

//reader.digitale-sammlungen.de/en/fs1/object/display/bsb10286515_00005.html

About ROBERT FRORIEP (1804-1861): He was a well-known German doctor. He was the prosector of the Pathological Museum at Charité Hospital in Berlin (1833-1846), and he was the mentor of RUDOLF VIIRCHOW (1821-1902).

What is FRORIEP’S theory?

Froriep’s main theory is that the acute and chronic rheumatic pains are related to an EFFUSION IN THE CELLULAR TISSUE (of the cutis, of the subcutaneous tissue, of the muscle, and the periostium). This effusion could be felt as an INDURATION localized or generalized in an area (with nerve supply), limb or complete half or whole body. Sometimes the effusion could be palpated with borders, as a rounded nodule or like a tense band, or just like a generalized induration or crackling.

So he is somehow defining what has been called “mice”: congested, edematous or infiltrated fibro-fatty tissue that is felt as nodules or painful points.

In his book he does not only mention the indurations of the muscle, “Muskelschwiele”, but he also talks about the indurations of several layers of the connective tissue; muscle tissue is just one of them. Actually, he mentions that the most common places where the rheumatic “schwiele” or “induration” occurs are the dermis and subcutaneous tissue.

According to Froriep’s theories, the effusion would be caused by an alteration in the capillaries, by vessel dilatation, plasma effusion, and that could be related to certain “nerve impairment”.

FRORIEP’S cases prove that, by electromagnetic therapy, the normal function is restored

Froriep published this book in 1843 to illustrate the good results he obtained by the use of the electromagnetic therapy in the treatment of acute or chronic rheumatism. He mentioned that he used NEEDLES to make electro acupuncture, in some cases, to reach deeper tissues.

In the original book from 1843, Froriep published several drawings of the electromagnetic device and the needles to perform electro acupuncture.

The two books have a wide content about several case reports to illustrate the benefits of the treatment with electro-magnetism in a variety of the so-called “rheumatic affections”, related to what he describes as RHEUMATIC EFFUSIONS or “AUSSCHWITSUNG” or “EXUDATION”.

He divides his work in 4 main chapters:

1-Effussion into the cutis or “AUSSCHWITZUNG in der Cutis” or “Hautschwiele”

2-Effusion into the subcutaneous cellular tissue or “Hautzellegewebsschwiele” “Zellegewebeschwiele”

3-Effusion into the muscles or “Muskelschwiele”

4-Effusion into the periosteum or “Knochenhautschwielen”

MOORE-LAWRENCE decided to translate the famous Froriep’s term “Schwiele” as “induration” and “AUSSCHWITZUNG” as “effusion”.

There are 14 chapters related to different rheumatic affections, each with some illustrative cases that resolved with electromagnetic therapy.

Froriep’s pathognomonic sign:

In his introduction, Froriep’s mentions that the presence of this “rheumatic effusions” could be considered a pathognomonic sign of the rheumatic affections, since they increase or decrease as the symptoms get worse or improve.

Froriep’s “Muskelschwiele” concept:

Froriep described clearly in his book the theory behind what he named Muskelschwiele. This MUSCULAR INDURATION would be the consequence of a rheumatic effusion in the cellular tissue of the muscle. This concept has been completely misunderstood nowadays. Its pathognomonic sign would be an “effusion from blood plasma” that indurates the cellular tissue. Then, it can be palpated in different ways, like nodules, hardness, or bands. He DOES NOT MENTION a MUSCULAR CIRCUMSCRIBED CONTRACTION (a concept closer to the myofascial theory or trigger point theory) in any part of his book.

In Chapter VIII he presents rheumatic backache cases (later, I transcribed the 3 cases)

Froriep’s described how the palpation of the back tissue felt as follows:

[…there was on either side of the vertebral column a peculiar hardness of the muscles, which felt like cords, and on pressure, the muscles slipped away and crepitated]

Froriep mentions that the patients improved immediately after galvano-puncture.

MY PERSONAL NOTES ABOUT THESE BOOKS:

• Moore-Lawrence does not include all the information from the original book. For example, the information about the device with all the drawings of the electric machines and the needles is missing.
• He does not mention the theories about the nature of the effusion. What is it made of? He just mentions that it is the consequence of a vessel dilatation. The vessel dilatation would be due to “certain” nerve impairment. Then, by electricity, they produce vasoconstruction and reabsorption.
• The climatic changes: they made continuous reference to the influence of the weather changes as a precipitator of the rheumatic afflictions. BUT he does not propose any explanatory theory. He does not mention any effect of the air humidity.
• He mentions that by applying the electric current through NEEDLES by acupuncture (in the original book there are the detailed drawings of the needles), he obtained quick relief.
• There are NO IMAGES of the body spots where the electricity was applied.
• HE DOES NOT MENTION any bibliographical review or other authors’ thoughts.
• He DOES NOT mention any dissection work.
• He does not mention his theory of the composition of the effusion; it seems he suggest it is just an effusion from the blood through the capillaries.
• His case reports are related to a big variety of pain syndromes.

TABLE of contents OF THE ORIGINAL TEXT

____________________________

As follow I just copy the original text from the translation of RICHARD MOORE-LAWRENCE of FRORIEP’s book. I just added some titles to better organize the text. Between [ ] it is exactly an original copy.

ON THE THERAPEUTIC APPLICATION ELECTRO-MAGNETISM IN THE TREATMENT OF RHEUMATIC AND PARALYTIC AFFECTIONS.

 BY ROBERT FRORIEP,

 DOCTOR IN MEDICINE AND SDEGERT, PDELIC PROFESSOR OF GENERAL SURGERY IN THE UNIVERSITY OF BERLIN,

Translated by

 RICHARD MOORE LAWRENCE, M.D.

 SURGEON EXTRAORDINARY TO H.R.H. THE DUKE OF SAXE COBURG AND GOTHA.

MOORE LAWRENCE’s PREFACE noticing the value of the electromagnetism

[Having had, through the kindness of Dr. Froriep, an opportunity of witnessing the application of electro-magnetism in the treatment of many of the following cases, I was convinced that it was a valuable remedy in the treatment of rheumatic complaints, and my own subsequent experience has strengthened this belief.

 The therapeutic value of electro-magnetism has never been fairly tried — it has been resorted to as a universal remedy capable of effecting impossibilities when all other remedies have failed ; from this its want of success has arisen, and consequently it has not been duly appreciated. The desire to bring this remedial agent into more general favour, has induced me to undertake the translating of this work. October 1850]

FRORIEP’s introduction: THE CONCEPT OF EFFUSION, a common symptom yet unknown, a “pathognomonic sign” of the rheumatic affections

[Rheumatic affections appear under various forms, as those of pain, loss of sensation, convulsions and spasms, trembling and complete paralysis, swelling, and of atrophy. The different forms that this common complaint assumes will, in some measure, explain why it has not been better understood.

There are some pains and forms of paralysis arising from rheumatism which closely resemble neuralgia and paralysis; and in endeavouring to distinguish them we must consider the rheumatic disposition and the influence of atmospheric changes.

We must, therefore, search for some characteristic sign of the rheumatic nature of the complaint; a sign which can be perceived, and which holds an invariable relation to the continuance of the complaint.

 To find a new and hitherto unobserved symptom in a complaint of such common occurrence seems nearly impossible ; yet in other things how frequently it happens that something is pointed out which has escaped previous observation, and that then every one is surprised he should never have noticed it !

 This is the case with the effusions which I have observed to be a constant and characteristic sign of rheumatic disease. As far as I am aware they have never been considered of diagnostic value, and still less recognised as a pathognomonic sign of rheumatic affections. Nevertheless they are not only present but easily recognised, and bear such exact proportion to the complaint, that in the ratio that the effusions increase or diminish, the other symptoms grow worse or improve.]

FRORIEP’s RHEUMATIC EFFUSIONS: the main characteristics

[Rheumatic effusion occurs mostly into the cellular tissue ; most frequently into the subcutaneous cellular tissue ; also into the structure of the corium ; into the cellular tissue, beneath the aponeuroses; into the cellular tissue of the muscles ; into the periosteum ; and into the serous membranes.

 This effusion is most apparent when situated in the subcutaneous cellular tissue, appearing striated and pretty sharply bounded when of little extent, but when diffused causing an elastic swelling of the limbs : this is the product of the rheumatic affection, but may also be described as the mechanical cause of the continued alteration of the nervous energy. I will give an example of acute rheumatism to remove any doubt as to the fact of its being rheumatism.

 Let us take, for example, an attack of acute rheumatism of the shoulder: we have pain succeeded by immobility of the shoulder and upperarm ; the pain is lasting and acute ; after a short time febrile symptoms set in, when, if we examine the shoulder, we find a tense swelling, with a red and shining surface. At first it is only oedematous, but afterwards hard and extremely tender.

 The skin is dry and hot. On proper treatment being adopted, the fever diminishes, the pain and tense shining swelling subside, and the complaint generally assumes the chronic form : the patient complains of debility of the upperarm : is not able to lift it, or to move it either backwards or forwards, or from the side of the body. Sometimes there is also a feeling of coldness and trembling in the forearm and hand. Not unfrequently instead of the continued or paroxysmal attacks of pain there is insensibility of the skin of the upper-arm, or fore-arm, or pricking and numbness of the finger ends. We all know how obstinate these affections are, and that even in fortunate cases from six to eight weeks are requisite to remove the impediments of the sensorial and motor functions in the limb.

 The impairment of motion has generally been attributed to the rigidity of the ligaments, because rheumatic inflammation was said to be inflammation of the tendinous structures. I have observed, on careful examination, a peculiar callous thickening of the cellular tissue beneath the skin, accompanied by much hardness and a general swelling of the surface. In all cases I have remarked that these indurations are most intimately connected with the course of the complaint : the secondary appearances, as pain or want of sensibility, immobility, or trembling, improving in corresponding ratio with their diminution.

 Having made these observations, I endeavoured to make myself more fully acquainted with effusion as a symptom. I then found that it might be situated in the corium, but is most frequently in the subcutaneous cellular tissue. It occurs also in serous cavities: however, I shall not enter into this at present, but reserve my observations on articular rheumatism for another occasion, confining myself here to effusion into the cellular tissue.]

1-The effusion into the cutis

 [Induration* ” Schwiele ” is the term employed by Dr. Froriep) of the corium is thus distinguished : the skin, without being much raised, seems much thicker, of a peculiar, almost cartilaginous, stiffness, can only be pinched up in a thick fold, can be moved over the cellular tissue below, though not so freely as healthy skin, especially over bony surfaces.

A fold of skin pinched up looks tumid, thick, and smooth, and if more compressed has a shining appearance, which, in healthy skin, it is impossible to produce. The colour of these places is mostly lighter, whitish, or fallow, which marks the effusion very distinctly : they can also be recognised by the touch. The effect of stimulants (which produce cutis anserina in healthy skin) is very peculiar on these places ; for instance, the application of the electro-magnetic current, which of late I have very frequently used in the treatment of rheumatic affections. If, by applying a powerful current to the cutaneous nerves, cutis anserina appears on the skin of one of the limbs, those parts which are the seat of rheumatic effusion are not affected, but remain quite smooth. This is most striking when, owing to the treatment employed, the effusion has decreased; then the cutis anserina may be seen encroaching on the former smooth surface in stripes or spots, giving a spotted appearance to the skin. These spots gradually disappear, and with them the complaint, except where the effusion is not confined to the cutis, but implicates deeper-seated structures.

 These effusions produce various changes in the sensibility of the skin : for the most part it is blunted to the external touch, which is felt as a pressure, but cannot be so nicely distinguished as by skin in a healthy state, and they generally render it more susceptible of atmospheric changes.

The parts where effusion exists are not painful when touched, but their sensibility is sometimes decreased, though oftener increased, by the passage of an electro-magnetic current : they are also subject to peculiar sensations, as a feeling of cold, or of a dry burning heat and itching. Pain is the symptom which most frequently accompanies this effusion into the cutis in all forms of rheumatism, such as sciatica, loss of sensation, and rheumatic paralysis. The secretion of these smooth places is checked, and I have seen the surrounding skin bathed in perspiration whilst they remained quite dry.]

2-The second and most frequent form of rheumatic effusion is that which takes place into the subcutaneous cellular tissue — the induration of the subcutaneous cellular tissue

 [This is found either in small circumscribed spots, or spreading over a limb, half the body, or the whole body. The effusion which is confined to parts supplied by the ramifications of a nerve is remarkable. It can be recognised at once by a slight swelling and by the skin over it having a shining appearance, and not admitting of being pinched up in a fold. Upon examining the swelling, it will be found firm and sometimes hard, and it does not pit on pressure unless that has been employed for some time.

 When these eff’usions are circumscribed, their margins may be distinctly felt, and the adjoining cellular tissue is pliable and easily pinched up into a fold. Where they are extensive, the surfaces over which the effusions are spread look swollen and disfigured, the skin is smooth and shining, but seldom changed in colour, and the margins are clearly defined, especially where the cellular tissue lies over a hard surface, as the forehead or front of the leg. When these indurations are diffused over an entire limb as the leg, they cause a tenseness of the skin which renders it firm and unyielding.

 The surface is shining and full of indentations ; and, where the eff’usions are widely spread, the colour is changed to a bluish red, the skin cannot be pinched up in folds, the surface is cool, and the patient does not always complain of pain. The effect of the electro-magnetic current on these effusions is very marked : the application of it turns the surrounding skin red, whilst that over the induration remains pale, defining its extent.

 Cutis anserina is produced, provided the electrical stimulus be sufficiently powerful. These callous spots are generally extremely sensitive of the stimulus of electricity, and the passage of a current will discover their presence by rendering them very tender ; but it also happens that where the effusion is considerable the sensibility is lessened, or in places completely destroyed. This occurs principally when the induration is seated in the cellular tissue and corium.

 This form of effusion generally succeeds an attack of acute rheumatism, affecting different parts of the body, as the shoulder and upper-arm, &c., and is accompanied by chronic rheumatic pains, which continue for years, gradually depriving the patient of the use of his limbs, and not remitting until absorption of the induration has been effected, during which process the power of motion returns, and the pain decreases or increases in exact proportion as the induration improves or grows worse.

 Isolated rheumatic indurations are found in spasmodic contractions, but whether or not as the cause of the same I must leave undetermined. More extensive effusions are followed by stiffness, trembling, or by paralysis ; by the last especially in those parts where the superficial cellular tissue is not separated from the muscular by aponeuroses.

Rheumatic effusion into the cellular tissue of the face is generally accompanied by paralysis of those muscles supplied by the facial nerve. A slighter degree of extension beneath the skin of the face gives rise, though seldom, to a diseased excitability of the muscles, which become subject to spasmodic twitchings, being no longer under the influence of the will.

 A peculiar variety of these indurations in the cellular tissue, is a less indurated form, met with in persons wasted away from chronic rheumatism, or where a fractured limb has been kept motionless for some time. We sometimes find at the most pendant part of a limb, for instance, the ulnar side of the fore-arm, or back of the upper-arm, a loose pale swelling, which hangs like a bag. The surrounding cellular tissue is soft and yielding, but that of the swelling is firm, hard, and painless, and does not pit on pressure. These indurations are the seat and constant attendants of rheumatic pains, which spread from them over a limb, causing severe pain in one of the adjoining joints, undergoing exacerbation on each change of the weather and in high winds.

 As these indurations become absorbed, which, under any treatment takes place but slowly, the pains also subside. These indurations are very painful on the passage of an electro-magnetic current, which produces no change of colour : they are not painful when pressed, and the skin over them maintains its sensibility unimpaired. Chilblains resemble these indurations in which not only the cellular tissue but also the corium is indurated, and of a bluish-red colour. The treatment of chilblains is well known ; but it may not be so well known that similar swellings arise on the backs of the fingers and hands in rheumatism, especially in partial rheumatic paralysis, which can be cured by the stimulus of the electro-magnetic current.]

3-The third variety of rheumatic induration is situated in the muscles — muscular induration

 [Which, in consequence, feel hard and unyielding. Sometimes when there is less effusion, they are like a muscle when firmly contracted, and in time lose their size, become atrophied and thickened, and when laid hold of feel like a firm tendinous band.

A striking peculiarity in this last variety is, that the muscle in places cannot be moved over, and, on examination, seems adherent to the surface of the bone : the cellular tissue around it is sometimes soft and yielding, in fact quite healthy, sometimes it has become callous, and is easily moved over the muscle, or the callous muscle is covered by a slightly-callous cutis and healthy cellular tissue.

 The muscular induration is generally insensible; but occasionally there are places which, when pressed, are painful, and feel as if there was a sore beneath the skin. This muscular induration is attended with more or less loss of flexor power, arising not from pain, but from the diminution of the contractility of the muscular fibres. If we endeavour to excite the muscles to contract by the application of an electro-magnetic current, we shall have no reaction where there is much rheumatic effusion, the muscles remaining quite passive even on the passing of a powerful current ; forming a striking contrast to paralysis proceeding from an affection of the nervous system. This difference of action of the electro-magnetic current on the muscles is of great imaportance in distinguishing paralysis caused by disease of the nervous system from rheumatic paralysis.

 The functions of the muscles are impaired in degrees varying from mere stiffness to the entire loss of all voluntary motion ; whilst passive motion is possible, though sometimes restrained by the acute pain brought on in the joints and other parts. A feeling of stiffness sometimes attends each voluntary movement of the muscles after they have been at rest, or an awkwardness in their use is felt, rendering the patient’s whole attention necessary when any act is to be performed, or a slight trembling follows each movement, which may gradually increase to complete paralysis agitans ; and, added to this, there is a disagreeable sensation of weight or feeling of tension and stiffness of the affected limb, and not unfrequently lancinating pains, which, with the trembling, are increased by change of weather.

 This trembling is very often accompanied by a slight restriction of the full use of the part, and may, I think, be considered to arise from partial paralysis, or from suspension of the equilibrium between the antagonistic muscles, or from the continued half-involuntary effort to restore this equilibriuin, and, therefore, during sleep and whilst the trembling limb is supported it ceases.

 In bad cases, when all the muscles are implicated in rheumatic effusion, this trembling results in complete paralysis, contraction or rigidity of the affected limb. In these cases all voluntary power is lost ; the limb does not dangle loosely by the side, but hangs down stiff and motionless, and its position may be more or less easily changed. When certain muscles only are the seat of the effusion, we find it confined to those which are supplied by one branch of a nerve ; and, in such cases, it is not always accompanied by stiffness of the part, and some muscles only are paralysed, whilst various distortions are caused by the antagonistic muscles.

 Paralysis of single muscles has, I believe, never been recognised as arising from rheumatism ; but the fact that such is the case, deserves further investigation on account of its importance in a diagnostic and therapeutic point of view. The characteristics of effusion in the muscles are indurations of the cellular tissue and cutis, giving rise to a pale, cold, and hard swelling, over which the skin is stretched and shining, and sometimes traversed by distended cutaneous veins, ramifying in different directions.

 In the flexures of the joints, and on the back of the hand and foot, the swellings are thicker, more cedematous, of a bluish-red colour, and pit on pressure. When the effusion is confined to a group of muscles, there is generally over this group a distinct circumscribed induration of the cellular tissue, which, according to my observation, is so constant a symptom as to be a diagnostic sign of the cause of the paralysis ; though, at the same time, I must mention that I have seen paralysis arising from disease of the nervous system followed by effusion.

 It may be known when the complaint is of a rheumatic nature by the accompanying lancinating pains and the marked influence of atmospheric changes ; yet these symptoms are not unfailing, rheumatic paralysis being sometimes unattended by pain.

 Another important symptom is the decreased sensibility of the cutis over the effusion, there being not only a feeling of coldness, but an actual decrease of temperature, influenced by the weather, the surrounding parts appearing of a red or reddish-blue colour. The limb feels warmer and looks redder on the passage of an electro-magnetic current ; and from its continuedapplication, the superficial and deep effusion become gradually absorbed, the use of the muscle by degrees returns, and may be entirely restored, the improvement exactly keeping pace with the progress of the absorption.

 Treatment. — Electro-magnetic currents, shampooing, warm baths, iodine, alkaline lotions, and promotion of local perspirations. The absorption in any case proceeds but slowly. Generally these cases of paralysis appear to arise from disease of the nervous system, particularly of the spinal cord : they are not benefited by stimulants, and we must try to cause absorption of the effiision, thus giving freedom to the muscles when the vis nervosa will again cause them to contract]

4-And, lastly, I have seen effusion into the periosteum — periosteal induration

[Which is very seldom found existing alone, there being generally at the same time effiision into the subcutaneous cellular tissue and cutis. If such complications are not present or have been removed, small oval swellings may be felt on the subcutaneous surface of thinly covered bones. These swellings may be called rheumatic nodes. The accompanying symptoms, as far as they can be recognised by sight and touch. depend on the effusion into the structures above.

 There is only one symptom which may be referred to the effusion into the periosteum, viz., pain, which is always very severe and lacinating through the limb, beginning at the nodes, where it is most acute : pressure upon these spots is not generally painful, but the application of the electro-magnetic current is so sensibly felt that it may be used for pointing out their situation. This increased sensibility fan intolerable sensation of heat) is exactly confined to the extent of the effusion.

 Another but not a constant symptom met with in these rheumatic nodes is a feeling as if the limb were at one particular spot broken or paralysed across. Those cases which are attended with effusion into the periosteum are among the most violent and obstinate of rheumatic complaints, often assuming the form of neuralgia, or of some deep-seated disease of the bone, and requiring very energetic and persevering treatment to produce absorption. I have never seen exostosis resulting from rheumatic nodes.

The affection of other organs?

The sheats of the nerves or the medullary canal:

[It is a question whether other organs are not also the seat of rheumatic effusion — the sheaths of nerves, for instance. I will not deny the possibility, though I must confess that I never saw a case ; nor, as far as I am aware, have those who have written about effusions into the sheaths of nerves ever recited a case, where they have been found on dissection; and, for my own part, I am inclined, from a twofold reason, to doubt whether they occur at all. First, because the symptoms which have been attributed to effiision into the neurilema may be more satisfactorily referred to the easily-recognised induration of the cellular tissue and muscular structure ; and, secondly, because in two cases of gout, in which the symptoms of pain and paralysis seemed to indicate that efhision had taken place into the neurilema, I made a minute examination of the nerves after death, and traced them up to the spinal cord, without finding either any effusion or tumefaction. I do not think it, therefore, too much to demand that, as the occurrence of effusion into the sheaths of nerves in rheumatism cannot be externally felt, the anatomical proof of its existence should be demonstrated before we are required to give it our assent. Whether rheumatic efiusion occurs into the medullary canal is not known.]

The effusions into the serous cavity:

[The Effusions into serous cavities take place ; but as they produce different results to the rheumatic induration, this is not the place to consider them.]

The next question is, are these rheumatic effusions the result of inflammation, or of perspiration having been checked?

[The first symptoms only lead us to the conclusion that inflammation is the cause ; but from the subsequent course of the complaint we should draw a different inference. The theory that the checking of the excretions of the skin is the immediate cause of the deposit of fluids beneath the skin is evidently too mechanical, and proceeds from wrong views of the process of secretion; but there is a function both in inflammation and secretion which deserves consideration, — I mean the nervous energy.

 Every appearance of change in the body, whether physiological or pathological, commences with an effusion which at first is necessarily fluid, and is carried along by the blood from which it is secreted. This formative fluid exudes through the coats of the vessels. This is the first mechanical process in nutrition, also in congestion, inflammatory effusion, and in every case where fluids pass from the circulation into the surrounding structures.

 This exudation of a portion of the blood through the coats of the vessels is common to all exhalations. The question arises, What causes the fluid to escape from its natural channels ? It may happen either from some alteration in its consistence or composition, from congestion, from debility, or from some change in the texture of the sides of the vessels.

It is well known that these are porous, that the external and middle coats are composed of fibres, and the inner one of a thin serous membrane. The fluid of course escapes more easily when the porosity is increased, and a membrane composed of fibres must naturally be more porous when distended, the spaces between the fibres becoming larger. Therefore, in every case where the blood is not altered, effusion is preceded by a distension of the vessels, which may be caused either by congestion, debility, or relaxation of the coats of the vessels.

 Henle directed his attention to this subject, as appears in his works on Pathological Investigations and General Anatomy, and says, in the last work (page 522), ” Increased contraction of the capillaries causes paleness, and restricts the escape of the plasma ; atony and paralysis of them produce redness and an increased collection of the plasma ;” and comes to the conclusion that paralysis of the capillaries is the principal cause of congestion, inflammation, and effusion. It cannot be denied that the vessels contract, since Schwann saw them contract beneath the microscope on the application of cold ; and Valentin has also observed the same result from irritation of the nerves supplying them.

 The contraction of the capillaries is induced by effects of temperature, mechanical, chemical, and electrical stimulants. This is proved by the experiments which have been made with solutions of salt, sal volatile, cantharides, and alcohol on the veins and capillaries : contraction of the veins has been produced by pinching them with forceps; and I have often seen distended vessels* contract on the application of an electrical current, the part stimulated becoming pale. I have frequently produced in the cutis and contractile tissues, by the stimulus of electricity, cutis anserina, which results from the same psychological impressions that give rise to increased contraction in the muscles. If by this it appears that the vessels are affected by the same excitants as the muscles, a great difficulty opposed to this theory will be removed, and it will also derive an important support if juvantia et nocentia prove the same]

[* Dr. Golding Bird remarks in his lectures, — “We have seen that electricity, under all its modifications, is a most energetic agent in exciting contractions of muscular fibre. This susceptibility to the stimulus of electricity is not limited to real muscular tissue, but is equally participated in by those white contractile tissues, which, by some physiologists, are hardly regarded as belonging to the class of true muscles. I allude particularly to the muscular coats of arteries, intestines, and bronchial tubes, as well as the structure of the uterus.” Dr. J. C. B. Williams has actually demonstrated the contractibility of a bronchus under the influence of a current of voltaic electricity. — Ed.]

The theory of the DILATATION OF THE VESSELS…

[The next question is, do effusions arise from relaxing and disappear from

contracting causes ? This is known to be the case in inflammation — for example, a contusion is followed by a reddish-coloured swelling and inflammation, which subsides on the application of cold or evaporating lotions. We have the same again after frost-bites : the first visible effect of cold is, that the part becomes of a dull red colour, in consequence of a diminution of the quantity of blood conveyed by the arteries, and a stagnation of it in the veins : if the cold continue, the blood is gradually expelled by contraction of the tissues, and the part becomes livid and pale.

 Sudden alternations of temperature cause redness of the skin, and swelling, owing to the distension or relaxation of the vessels, and stimulants are required in order to excite them to contract.

 As dilatation of the vessels is caused by relaxation and removed by stimulation, so also in rheumatic effusion. The proximate cause is some influence which weakens or paralyses the nervous energy in some part ; which results follow the continued abstraction of heat. But if the products of rheumatism are formed, they can only be removed by such means as stimulate the nerves of the parts affected, so that contraction of the vessels supplied by these nerves ensues as a secondary consequence.

These remedies act directly and indirectly. Those which act directly are mechanical stimulants, as shampooing, rubbing, passive and active motion, and electricity ; those which have an indirect influence are stimulating applications, the effect of which is explained by the reflex function, though we must admit that some advantage is derived from the local application.

 The analogy of the mechanico-physiological process in other effusions, and also the result ex juvantibus et nocentibus, prove that the rheumatic induration proceeds from a diminution of the vis nervosa.

 If we come to the conclusion, that rheumatic efiusion is the effect of the disturbance of the nervous system, and consider rheumatism as peripheric disease of the nerves, it is not difficult to explain, why in rheumatic affections symptoms of apparent disease of the nerves, as paralysis or pain, should be superadded to such an extent as scarcely to bear any proportion to the exciting cause ; whilst the rheumatic affection is only considered as the result of altered secretion and impeded perspiration, and not as the product of the change which has taken place in the irritability of the nerves.

This view will also explain why rheumatic disease continues until the exudation is absorbed ; for the effusion either obstructs mechanically the influence of the vis nervosa on the muscles or the brain, or shows the degree of the relaxation of the vessels and the diminished irritability of the nerves upon which the vessels are dependent.

 This theory of rheumatism accords more than any other with all the facts which have been recognised in respect to its etiology, the peculiarity of its course, its complications, and prognosis.

 And, with regard to the treatment, our object must be to invigorate the nervous system both locally and generally, to restore it to a healthy state of excitability, and to remove the effusions.

 This is to be effected, first, by removing debilitating influences ; secondly, by the application of such remedies as we know to act as stimulants in the normal condition of the nerves and vessels ; and, thirdly, by producing absorption of the effusions. In reference to the second indication, this caution must be given — not to allow the proper stimulants to be applied too long, because overstimulation is followed by depression.

The first indication will be accomplished by warm clothing, occupying warm rooms, avoiding exposure to cold, and by cleanliness.

 The second by general, and especially local, stimulants, as heat, vapour-baths, hot douches, stimulating and evaporating lotions, rubifacients, rubbing, shampooing, acupuncture, and electromagnetism.

 The third by the remedies named under the second indication, and especially by continued diaphoresis, produced by dry heat applied over the effusions, and the local inunction of iodine.

 Symptomatic affections and complications must be treated on general principles.

 In support of the opinions I have expressed concerning the importance of rheumatic effusion, I shall communicate a number of cases which I have had under my immediate treatment. I have been in the habit of using the electro-magnetic machine of Saxton,* and have very seldom em- ployed other remedies at the same time with electro-magnetism, wishing to ascertain without the possibility of a doubt its real effect. Currents maybe transmitted through the medium of sponges saturated with salt and water, and applied to the cutis, or by acupuncturation, when it is requisite to act energetically on parts deeply seated, by introducing two needles of platinum in the course of a nerve. I must however observe, that there are many remedies which when judiciously employed very materially assist the cure; but as I was desirous to test the therapeutic value of electro-magnetism alone in the treatment of disease, I seldom employed them ; and the following cases will therefore be of more interest to those interested in therapeutical experiments.

I shall relate some cases of acute and chronic rheumatism which seem calculated to exemplify the importance of rheumatic induration, and its relation to the disturbances of the sensorial and motor fimctions, which are met with as symptoms portance to induce physicians to make a serious study of electrophysiological phenomena, in order that by persevering efforts science may be advanced, and a therapeutic method discovered applicable to the cure of a disease which unfortunately has hitherto resisted every other form of treatment.” — Ed.

* The first magneto-electric macliine was invented by M. Hipolyte Pixii, of Paris, and was first made public at tbe meeting of the Acad^mie des Sciences in September 1830, a description of which will be found in the ” Annales Chimie ” for July 1832, and a representation of it in Becquerel’s” Traite de I’Electricite,” vol. iii. At the meeting of the British Association at Cambridge, in June, 1833, Mr. Saxton exhibited his improvement on Pixii ‘s machine, a description and engraving of which will be found in the ninth volimie of the ” London and Edinburgh Philosophical Magazine,” page 360 ; but now that we possess more convenient and simpler apparatus for the medical application of electro-magnetism, we should avail ourselves of the knowledge furnished by the electrophysiological researches of Matteuci and many others, and give it a fairer trial than it has hitherto had. Dr. Golding Bird, in his Lectures on Electricity and Galvanism, delivered at the Eoyal College of Physicians, observes, ” I am conscientiously convinced that the agent in question is a no less energetic than valuable remedy in the treatment of disease. I feel most anxious to press its employment upon the practical physician, and to urge him to have recourse to it as a rational but fallible remedy, and not to regard it as one capable of effecting impossibilities ;” and Mr. Noad, in liis Lectures on Electricity]

CASE REPORTS from I to XIV as examples of rheumatic effusion

 

I —ACUTE RHEUMATISM OF THE SHOULDER AND UPPER-ARM

 [Miss F., aged 38, slightly made, and of a nervous temperament, had been subject for several years to attacks of rheumatism, which generally commenced with fever, lasting from two to three weeks, and terminating in a chronic rheumatic affection. She had one of these attacks on the 10th April, 1842, and was attended by Professor Caspar. During the night of the 19th April, I was sent for in consequence of a great increase of the febrile symptoms and violence of the pain, the patient labouring under much nervous excitement, and declaring that she had been poisoned.

 The fever diminished after a couple of days, but the pains continued with unabated violence. April 1’^nd. She called upon me : I found the right shoulder and upper-arm very red ; on the posterior surface of the shoulder, passing over the deltoid to the outer-side of the upper-arm there was a large induration in the cellular tissue, which was very perceptible, from the skin over it being of a shining bluish-red colour, whilst the surrounding skin of the shoulder and upper-arm was vividly red. The swelling was firm, painful when pressed ; the skin could not be pinched up, and was the seat of severe lancinating pains, which extended from

the shoulder down the arm to the hand ; motion was so imperfect, from the pain and loss of power in the arm, that the patient was obliged to carry it in a sling, and not only support but also lift and move it about with the left hand, when the slightest movement was requisite. The pulse and general habit were irritable, but only to such an extent as could be fully accounted for by the violence of the pain, and entire want of sleep. In front of the shoulder there was a sore from the application of a blister. The pain, although most violent during the night, was also in the day-time so severe as to cause the patient to walk about moaning in spite of her exhaustion. I allowed the wound caused by the blister to heal up, and passed a weak electro-magnetic current from the shoulder to the hand, which produced acute pain in the induration ; but after it had been applied for one minute, there was so sensible a diminution of pain, that she suppressed every expression of suffering, lest I should be deterred from continuing its application. The colour of the induration on the upper-arm during the application was pale, with spots of dark-red ; after an application of four minutes all sensation of pain was removed. In the afternoon the patient had an attack of pain, less acute, and accompanied by less nervous excitement, which again passed off so as to allow her to have a quiet night’s rest, another paroxysm not occurring until morning, and then only lasting half an hour.

 23rd. The pain became greater and more continuous after rising at ten o’clock, but was removed by passing a current for seven minutes. After the application, the pulse was more frequent, though it did not exceed 80. The induration appeared white, spotted with red, and patient could, without assistance, raise the hand to the forehead, but, owing to the pain in the induration, which extended to the inner condyle, she could not move it backwards. With the exception of an attack of pain lasting for one hour, the patient felt so well during the afternoon that she could walk about the room without having her arm in a sling, and afterwards passed a tranquil night, being only disturbed a few times from violent perspirations.

 24th. Suffered from much depression, in consequence of erratic lancinating pains, which were quickly removed by the electro-magnetic current. The induration was a little softer, and the movements of the limb freer. 2bth, 27th, 2Sth. Electro -magnetic currents were applied; the motion of the arms gradually increased ; the nights were free from pain ; her appearance and general health greatly improved ; the induration softer and scarcely changed in colour on the passage of the electro-magnetic current. 29th. The arm was covered with an urticarian eruption, accompanied by slight symptoms of fever : the current had no effect upon it. May 1st. The eruption had disappeared. The patient was able to use her arm freely and without pain ; her nights were perfectly quiet, and no trace of the induration could be seen •, in fact the complaint was completely removed. In this case, by a local application of the electro-magnetic current for eight days, producing absorption of the induration in the cellular tissue, an affection was removed which, under the usual treatment, would have required from six to eight weeks.

 Acute rheumatism often assumes a chronic form, shifts from place to place, and is prone to recur from subacute inflammatory attacks. Rheumatic indurations accompany this form also, which can only be removed by absorption of the local effusion.]

II.— SUB-ACUTE ARTICULAR RHEUMATISM

[E. v., aged 19, a smith, whose previous health had been excellent, a stout muscular lad, caught in the month of April, 1841, a severe cold, from running during the night into the street without shoes or stockings upon an alarm of fire, and suffered from severe rheumatic pain and swelling of both ankles; the pain shifted to other joints, and was accompanied by a bluish-red swelling June \st. He was admitted into the Charite Hospital, and there had vapour baths. In fourteen days the pain was removed from the joints, but the ankles remained in the same state as at first, and at the end of a month, finding no relief from the treatment adopted, he left the Charite, and on the 21st July came to me. He walked and also stood with much difficulty from acute pain ; the toes were rigid, and about the internal malleolus there was an elastic, bluish-red swelling, which felt firm and slightly warmer than the surrounding skin ; the skin could neither be raised up in a fold or moved over the bone. I passed an electro -magnetic current through this swelling, which turned at first pale and then red ; the pain was entirely removed after an application of from five to six minutes to each foot. The patient left my house free from pain, which did not return for three hours, and was then less acute. 22nd. The swelling at the inner malleolus was considerably softer, cool, and but slightly redder than the surrounding skin. The pain was removed by the application of a current, and the patient remained, although he took a long walk, free from pain, until eight in the evening. 23rd, He walked with a tolerably firm step, and only felt inconvenience on stretching the foot. The swelling about the inner malleolus was nearly gone, the skin could be pinched up in a fold, and after the application of a current, there was no pain in the foot, and he could move it freely. 2Ath. There was hardly any uneasiness felt in the joint on walking. The swelling on the right foot was quite gone, that on the left felt soft and edematous, and was of a healthy colour. Every trace of pain was effectually removed by the application of a powerful current. A slight pain, which was first felt but half an hour before at the inner side of the right knee, was quickly removed, and he was able to walk as well as usual. 2bth. There was neither pain nor any other symptom to complain of: a weak current was passed through the ankles.

 2Qth. The patient came at the usual hour and was very dejected, in consequence of his right knee being inflamed. He had acute pain on treading on his left foot ; there was a bluish-red, firm, hot swelling over the patella, not pitting on pressure; the skin could not be pinched up in a fold ; the pain was augmented by gentle, but relieved by firm pressure. The left ankle was oedematous and painful, the right not at all. The electro-magnetic current took away the pain in the left ankle entirely, but that in the knee only remained away for half an hour. ’27th. The pain in the right knee was exceedingly acute, the swelling in front of the knee very hard, and the skin above slightly reddened 5 the skin over the right outer malleolus was reddened and painful, but the joints of both ankles could be freely moved, a continued gentle current, which was applied three times in the course of an hour, removed not only the pain, but also the swelling of

the ankles and of the right knee to such an extent, that nothing remained but a small, doughy, pale edema of the skin over the patella. He left me free from pain, and was able to follow his work for the rest of the day. The following day he sent to say that he felt quite well, and was not able to leave his work. I saw him on the 15th of August, the last week of September, and on the 1st of November, up to which time he continued well.

 In this case nothing was employed but electromagnetism, and it is very interesting to see symptoms which are analogous to those of rheumatism, subside quickly and completely from the effect of the electrical stimulus.

III.— INTERMITTING ARTICULAR RHEUMATISM

Major U., a tall, fine, healthy-looking man, aged fifty, always enjoyed good health, caught in the summer of 1841 several severe colds, and, for the first time, had an attack of articular rheumatism of the right knee, which was treated in the usual manner, and cured in a couple of months. In the autumn he caught a fresh cold, which gave rise to a very singular intermitting rheumatic affection. He had a rheumatic swelling of both knees, which suffered exacerbation every eight and a half days. On the first day he felt a painful stiffness in the right knee, which was slightly swollen ; on the second day this decreased, and during the night a troublesome itching of the left knee set in, which prevented him from sleeping. For twelve hours the left knee continued enlarging, until a doughy swelling, as large as a fist, formed beneath the lower portion of the vastus internus, and gradually implicated the whole of the knee, which, after motion, became exceedingly painful.On the fourth day the swelling had reached its height, and then began to decrease, and by the fifth day had nearly subsided. The lower portion of the vastus internus and the skin over the head of the fibula remained puffy, and there was a very unpleasant sensation of intense cold, which extended down the outer side of the calf to the heel. The right upper-arm, both elbows, and the fingers of both hands, especially those of the left, were then slightly affected. After the eighth day, there was a slight itching of the right knee, the affection of the elbows, and a painful stiffness of the loins, which was sometimes present, passed off, when the above-described symptoms recommenced. Patient had tried for four months different anti-rheumatic and anti-neuralgic remedies. Derivatives, leeches, stimulating and anodyne embrocations, diaphoretics, vapour baths, and douches, produced not even temporary benefit. His general health suffered but little.

 March I4th, 1842. When the patient consulted me, the swelling of the left knee had reached its height. It felt doughy and yet elastic ; was as large as half the hand, raised about an inch, of a vivid scarlet hue, not fluctuating, and only painful when pressed. There was no effusion into the cavity of the joint ; the knee could neither be straightened nor bent, from a painful feeling of tension of the extensor muscles of the leg. I recommended electro-magnetism, and the discontinuance of every other remedy. The passing of a weak current for a quarter of an hour through the above-mentioned parts, caused more freedom of motion, a great decrease of pain, and diminution of the swelling of the left knee. Ibth. There was much general excitement; but the whole the patient was better. 20th. The exacerbation began as before ; but was in every respect much less. The same treatment continued. The exacerbation recurred. April The exacerbation again recurred; but the right foot was only slightly affected. Sth. The swelling of the left knee was inconsiderable, and there was but little redness. The sensation of cold was no longer felt in the right heel, nor the doughy swelling over the head of the fibula. \2th. A very slight swelling of the right knee marked the beginning of another exacerbation. Patient was obliged to leave Berlin. 27th. The treatment was resumed ; no change had taken place in the complaint since he left. The exacerbations recurred at the usual period. The stiffness in the knees and elbows caused but little inconvenience. Over the left knee a small doughy swelling had become stationary, the skin over which could not be pinched up. May 2nd. There was only a stiffness felt in the joints of the right arm. I3th. Continued the same. The left knee was free from swelling and pain, and during the last week at the time of the exacerbation, no change was perceived. I5th. Patient went into the country, and from thence to Marienbad, in Bohemia. I heard two months afterwards, that he continued free from this intermitting affection.

 If in this case the inflammatory character was less marked, the existence of effusion into the cellular tissue, which is here our chief object, cannot be doubted, as the same places were compared before and during the exacerbations.

IV.— RHEUMATIC* GUM-BOIL [not trasncribed]

v.— ACUTE ARTICULAR RHEUMATISM [not trasncribed]

VI.— RHEUMATIC PAIN OF THE FOREHEAD, AND HYPERESTHESIA OF THE EYES [not trasncribed]

VII.— CHRONIC RHEUMATISM AND STIFFNESS OF THE SHOULDER [not trasncribed]

VIII.— RHEUMATIC PARALYSIS OF THE LEFT ARM [not trasncribeD]

IX.— RHEUMATISM OF THE SHOULDER AND UPPER-ARM [not trasncribed]

X.— RHEUMATIC PARALYSIS OF THE LEFT ARM

[Mrs. — , aged 37, a tall, pale, thin woman, whose countenance bore the expression of great suffering. In January, 1841, she had an attack of acute rheumatism, affecting both arms. The right arm was cured, but in the left the pain continued. She was treated at home for some time, then was six weeks in the Charite Hospital, where for four weeks sulphur baths were employed. Nothing afforded her any benefit : the left shoulder, upper-arm, outer side of the fore-arm, and back of the hand were the seat of excruciating pain ; she could not raise her hand as high as the neck: abducting the upper-arm brought on a paroxysm of pain ; the hand could not be drawn backwards, and was so weak as to be quite useless. At night the pain became so violent that she was obliged to get up and walk about. The shoulder and outer side of the arm looked like wax, were cold and firm, though the soft parts in other places felt flabby. Isolated spots on the upper-arm looked puffy and smooth ; the back of the hand was thin and of a bluish colour. June I8th, 1841. She came to me. I passed a very powerful electro-magnetic current from the shoulder to the hand, for ten minutes, which removed the pain, even that felt on passive motion ; the weakness continued as before. After the passage of the current, the skin had a strange appearance; the puffy spots before mentioned remained pale^ while the surrounding skin was very red : the effect of the current on these spots was particularly painful. The arm felt hot, and in some places burning, for the rest of the afternoon. 19^1^. She had a quiet night, and could reach the back of her head and the right shoulder. No return of pain, although she had been using her arm. 2lst She can move her arm somewhat more freely, and had been able to use it in knitting. 23rd. Could reach the back of her head so easily that she was able to arrange her hair. The upper arm was still puflFy, and on passing the hand over it several indurated places were felt. The hand was not so thin, nor any longer of a bluish colour. After the passing of a current the arm was spotted white and red, and for the rest of the day continued to glow. 24th. A very powerftil current was passed through the arm, after which she was able to extend it to her forehead. 26th. Again a powerful current was applied, and followed with so much benefit that she was able to reach her right ear. 28th. With the exception of not being able to raise the upper arm so high as to touch her ear with its outer side, she had the free use of her arm. ^^th. She was quite free from pain, the upper arm did not become spotted on the passage of the current, no indurations could be felt beneath the skin ; on raising the arm there was only a slight feeling of tightness. The hand was of natural temperature. She was able to do her work without feeling any inconvenience. She discontinued coming from this- date, and I did not again see her for more than twelve months, during which she told me that she had been quite well.]

XI— RHEUMATIC PARALYSIS OF THE LEFT UPPER-ARM [not trasncribed]

 XII.— RHEUMATISM OF THE LEFT ARM

[Mrs. S., aged 54, a short, thin person, had been attacked nine weeks before with pleurisy, and was bled in the left arm, which became the seat of very acute continuous pain. It was felt in the upper-arm, shoulder, and elbow to so violent a degree that she never had more than two hours sleep during the night. Narcotics, cataplasms, and stimulating embrocations afforded her no relief.

August 20th, 1841. The patient came to me by the advice of the medical man who had been attending her. I found that both active and passive motion of the shoulder caused severe pain ; she could not move the elbow two inches from her side ; flexion or extension of the fore-arm and fingers was impossible, and, consequently, rendered her unable to do anything for herself Pressure on the upper arm or the cicatrix of the venesection was not painful ; the latter could be freely moved over the parts beneath. The elbow was cool, pale, and puify ; and beneath the skin on the inner side of the fore-arm, and on the lower half of the upper-arm, there was an induration of the cellular tissue : the shoulder was surrounded by indurations which were adherent to the skin. The general health was good. The application of the electro-magnetic current was very painful over the induration on the inner side of the arm, but the motion of the limb was much benefited by it. Other day. A current was applied daily ; motion became daily freer ; pain was only felt on moving the limb ; the indurated swelling on the inner side of the arm was gone, but that around the elbow and shoulder was still apparent. Other day. Motion was a little freer, and she was able to attend to her household duties, and dress herself without assistance. On raising the hand to the opposite shoulder and backwards there was a tightness felt over the cicatrix and at the acro- mion. A current was applied. O.D.The same feeling of tightness ; the nights were free from pain. September 1st. She could move her arm in any direction without pain ; but on carrying anything with the arm quite extended, she felt a tightness over the cicatrix, the swelling and induration were quite gone. She remained away until September 12th, when a current was passed daily until the 15th, and every fourth day from that date to the D, by which period she was perfectl recovered. ]

 XIII.— RHEUMATISM OF THE LEFT ARM AFTER FRACTURE OF THE RADIUS

Mrs. L., aged 48, a short, thin person, had an oblique fracture of the lower end of the radius, which united crookedly, impeding the motion of the wrist joint. February 5th, 1842, patient came to me complaining of pain in the fore-arm, and of very acute lancinating pain in the upper-arm and shoulder. The motion was much restricted ; she had had no quiet sleep for months, and was quite worn out. I found, besides the tumefaction on the back of the hand and wrist, a large induration of the cellular tissue on the external and posterior surface of the upper-arm and shoulder, which caused the upper-arm to look round and plump, whilst patient appeared to have fallen away in every other part. The induration extended along the external and posterior surface of the upper-arm, felt hard, was pale and shining, and the skin could not be pinched up over it. Patient ascribed the pain to the employment of ice in the treatment of the fracture, as it first commenced a short time after the ice had been discontinued, and whilst the arm was kept motionless by bandages. It would be of no interest to follow the case day by day, and, therefore, I shall only give the following details. At first only the pains which began spontaneously were affected by the electromagnetic current, and she slept better. After the first week the nights were undisturbed by pain, and there was a slight increase in the motion of the fingers. 2ncl Week. The swelling at the back of the hand was less. 3rd Week. The induration of the upper-arm was less, allowing more motion in the shoulder, and the arm to be raised higher. Ath Week. The swelling at the wrist was confined to the ulnar side, and the fingers could be quite closed. bth Week. There was a very evident decrease of the induration in the upper-arm, and she could raise her arm so as to touch her right ear and shoulder. Using the left hand much caused the wrist to swell. I ordered it to be rubbed twice a day with a solution of the iodide ofpotassium.

7th Week. The induration in the upper- arm was quite gone, except a small place at the posterior surface, where the application was very painful. 8;fA Week. The arm could be moved freely backwards, but supination and pronation were not possible. The swelling on the ulnar side of the wrist was gone, and the motion of the fingers and wrist as free as could be expected, whilst the mechanical obstruction existed. Patient was now able to knit and use the hand pretty freely. \Oth Week. The effusion at the posterior surface of the arm was absorbed, and its movements were quite free. The symptoms in this case were much influenced by change of weather, especially the pain in the upper-arm and shoulder, which would begin in the night without any apparent cause. The swelling, pain, and loss of motion in the shoulder arose, I should say, from the injury to the wrist, the pain having commenced on the second day after the injury, and not from the application ofice to the wrist.

 XIV.— CHRONIC RHEUMATIC PAINS AND STIFFNESS OF THE NECK

[Mrs. M., a thin sickly-looking woman, had suffered the last eight years from stiffness of the neck, and acute lancinating pain extending from the nape of the neck to the top of the head, affecting also the forehead and upper-arm. The neck was bent so far forwards that her chin almost touched the sternum. The muscles of the neck were swollen, hard and like bands adherent to the skin through the effusion into the cellular tissue, which could not be moved over them, nor raised up in a fold. The back of the neck was swollen and hard, and the front was much atrophied ; the sternocleido-mastoidei appeared wanting ; they felt beneath the skin like flabby, soft, thin bands, and, on a cursory examination, the neck seemed to consist alone of the swollen muscles at the back. She could move her head forwards, backwards, or sideways ; she complained of a feeling of great pressure in the nape of the neck and shoulders, and suffered the most agonizing pain, which, for the last two months, had increased in the night to such a degree as to deprive her of all rest. The disease had been gradually getting worse in spite of all the treatment adopted, and for the last two months had become very violent ; Russian vapour-baths which, on one or two occasions, were attended by slight benefit, being the only things that had afforded any relief. The neck was quite motionless : the most annoying symptom was a lancinating dragging pain extending from the nape of the neck to the top of the head and forehead, and feeling as if a claw had laid hold of the scalp, and was dragging it together. June 7 til, 1842. An electro-magnetic current was applied for the first time, and it was followed by an easier night than she had had for two months. 8^^. The tightness of the scalp was less; the neck was capable of a slight degree of motion sideways. The current was repeated. 9^A. The current was repeated. 10 th. The muscles of the neck felt softer. \2th. The pain lasted only two hours. I3th. The neck was much softer; the dragging pain felt in the scalp was gone ; the pain in the shoulder was very seldom felt, and lasted but a short time. The patient made rapid improvement. The current was continued ; and I ordered the unguentum iodinii compositum to be rubbed into the muscles of the neck, to hasten the absorption of the effusion. At this stage of the case this work was in the press, so that I am not able to state the result, though I entertain no doubt of its successful termination.]

PRESENCE OF INDURATION

Having now, I hope, established the value of rheumatic induration in the diagnosis of acute and chronic rheumatism, I shall extract from my notebook some cases in which certain parts of the body, or parts supplied by the branches of a nerve, are affected, and which can easily lead to diagnostic errors.

 A compilation of such cases must be of considerable practical value, as they show how these chronic rheumatic effusions cause, and are connected with, the various disturbances in the sensorial and motor functions. The accompanying symptoms appear sometimes as hypersesthesia, anaesthesia, paralysis, clonic and tonic spasm, and as atrophy.

 Rheumatic effusion is, in all these cases, the diagnostic sign; its application is simple, and its decision can be relied on. The presence of induration always proves the rheumatic origin of the disease. But the demonstration of the diagnosis being correct in the following cases, is evidenced by the fact that the anti-rheumatic treatment and resolution of the indurations always succeeded in curing them.

 The proof that the rheumatic effusion holds a definite relation to the symptomatic disturbance of the functions, is afforded by the symptomatic form of the disease decreasing or disappearing in the same proportion as the effusion decreased or softened. The fact that I have procured the absorption of these indurations, entirely through the agency of electricity, may suggest that this is a remedy which acts directly on the nerves, and by which their increased or diminished irritability has been restored to the normal condition, without the presence or absorption of the induration having exercised any specific action.

 To refute this argument I can prove that the unguentum iodinii compositum alone has removed paralysis, by effecting the absorption of the callous effusion. I think no one will maintain that when this remedy was alone employed, it acted only as a nervine ; therefore, the conclusion is evident, that when the electrical stimulus produces absorption of the induration, and cures rheumatic paralysis, it first stimulates the absorbents at the diseased spot, and in this manner indirectly removes the paralysis.

 This observation explains why, in such cases, I now employ the ung. iodinii compositum and vapour-baths, along with electro-magnetism, with which combination I have every reason to be satisfied, although I have obtained the same result in nearly as short a time with electromagnetism only. During my experiments on the therapeutic value of electro-magnetism, I confined myself to the application of it alone ; but now that I am acquainted with its power, I employ the many other remedial agents we have in addition.

RHEUMATIC EFFUSIONS SPREAD OVER THE BODY

I-PARALYSIS OF THE RIGHT ARM AND OF BOTH LEGS

[In the following case nearly the entire body was covered with rheumatic effusions, and several medical men were of opinion that the paralysis was occasioned by disease of the brain or spinal cord. At the time I write it is still under treatment ; but the result so far has been so satisfactory, as to justify me in speaking positively as to the cause of the complaint. Mrs. M., aged 58, had been very strong and robust; caught cold, whilst washing, eight years ago. At first she was seized with acute lancinating pain in her limbs, and difficulty of moving the left leg, which was swollen up to the knee. After using diaphoretics for a few days, the pain in the left foot suddenly subsided, but the next morning she awoke with a stiffiiess in the right arm and leg, the latter being swollen and very painful ; the arm and hand were quite powerless, and had lost all sensation, for she accidentally burnt her elbow without being aware of it. The sensibility of the hand and arm gradually returned, but accompanied by very violent shooting pains, which, especially in windy weather, became insufferable. May 23rd, 1842. The patient placed herself under my care ; the right shoulder was drawn up, the trapezius felt hard and stiff, the upper-arm was very thin, and the cellular tissue at the back of the arm was indurated. The muscles were atrophied, and seemed adherent to the bones. On the fore-arm and hand was an induration of the cellular tissue, which, on the back of the hand, felt pufly. The muscles of the fore-arm had lost their turgidity, and felt hard. The fingers were firmly contracted, requiring considerable force to open them. Sensation in the arm and hand was feeble. Motion was quite gone; the arm hung down by the side, not loosely, but as if the joints were stiff, and most agonizing lancinating pain was felt in walking, unless the arm was supported. She had very acute pain in the left hip, where the skin was indurated. In both legs there was a firm elastic swelling, over which the skin was dry, tense, and shining, and covered with brown scaly spots. Several distended veins could be seen ramifying through the skin. The ankles were much swollen, the feet were blue and cold, and she could neither move them nor the toes, consequently she stood and walked with great difficulty, and complained of a very wearisome pressure on the right shoulder.

The rheumatic nature of the induration was charac- terised by the electro-magnetic current not having the slightest effect upon any of the affected muscles. A current was applied daily, the legs were fomented with lye, and afterwards with an alcoholic solution of iodide of potassium. 2nd Week. She had lost the feeling of weight on the right shoulder, and can walk about, with the arm hanging down. SrJ Week. Arm and legs felt lighter ; she had continuous severe shooting pain ; the electro-mag- netic current had produced no change in the skin or muscles, but now the skin of the shoulder and upper-arm reddened, and cutis anserina was seen here and there. The trapezius was a little softer, also the induration at the back of the upper-armand over the deltoid. 4:th Week. The electro-magnetic current produced slight muscular contractions in the trapezius, triceps brachii, supinators, and peronei muscles. bth Week. The swelling of the hand was less, the fingers not so firmly contracted, the muscles of the fore- arm softer, extension and flexion of the wrist free. On the application of a current to the triceps, the fore-arm was a little extended ; on the biceps it produced barely any effect, and the trape- zius was powerfully contracted, raising the shoulder. 6th Week. She could abduct the elbow about six inches, and lift the fore-arm on to her lap. The muscles and cellular tissue of the leg were softer ; she had more voluntary power over the muscles. Walking was easier, though, from the motion of the ankle being confined, she was obliged to take short steps. 7th Week. The electro-magnetic current acted on the muscles of the fore-arm, the swelling of which, and also of the hand, was much diminished ; the hand could be easily opened, and also partially closed at will ; the fingers could be extended. Sth Week. The muscles of the arm and leg were softer; were all acted on by the electro-magnetic current, and subject to the will, with the exception of the extensors of the fingers. Windy weather brought on a paroxysm of pain, which was much less severe than formerly ; the nights were free from suffering. Ung. iodinii comp. was employed.Wth Week. Treatment was resumed: she progressed very satisfactorily. The swelling of the right hand was being rapidly absorbed, the elbow could be voluntarily bent until it formed an obtuse angle ; the right shoulder could be lifted up and lowered •, the motion of the feet and toes was nearly free, and the anterior surface of the leg was no longer shining. \2th Week. The swelling about the ankle is very much less.]

HEMIPLEGIA RHEUMATICA

[We will now consider those cases of rheumatic effusion occupying one-half of the body. I have met with four cases, which, at the present moment, are under treatment, but considering that they are of much interest in a diagnostic point of view, I shall relate them, and the result of the treatment. The general opinion is, that affections which attack half the body are caused by some disease of the brain. If I assert that the following four cases are peripheric affections, my opinion will receivemore consideration, by stating that, until Bell’s discoveries, hemiplegia of the face was believed to be caused by apoplexy, but is now considered as peripheric disease of the facial nerve. The most important diagnostic symptom is the induration in the cellular tissue. ]

XVI HEMIPLEGIA AND ANAESTHESIA OF THE RIGHT SIDE

[Baroness S., aged 36, healthy complexion, and general health very good, but subject to nervous headaches and neuralgia. In the beginning 1841 she had a severe attack of neuralgia costalis, which was removed by galvano-puncture. The subsequent use of steel medicines, and drinking the waters of Pyrmont, enabled her to pass the second half of the summer in pretty good health. She had, during the winter, occasionally shooting pains in her right arm, and in the month of February the finger-ends felt numb. On the right fore-arm there was a spot, which always felt cold and numb, as also did the whole of the upper arm, and right side of the head and foot. This was succeeded by a feeling as if a cushion were beneath the sole of the foot ; the numbness in the fingers increased, and the right fore-arm began to tremble. Pain was seldom felt, but the numbness on the right side of the head was very annoying on combing the hair. Cold had no effect, except when driving out in the cold, which brought on violent shooting pain in the forehead and right eye. Patient would not consult her medical man until her illness could no longer be concealed, in conse- quence of the trembling of the hand, and anaesthesia of the face. Blisters, stimulant embrocations, and unguentum veratri, rubbed into the back, were productive of no benefit, and patient having, on a former occasion, derived benefit from electro-mag- netism, again consulted me, and I applied a current, which, after an application of three weeks, removed the trembling and cold feeling, and diminished the shining induration in the cellular tissue near the neck. She had sometimes a dull heavy pain be-hind the right ear, and a singular affection of the vision, causing distant objects to appear as if moving about ; with each eye separately she could see quite well. The sight of the right eye was not so good as that of the left. Patient became very anxious and alarmed, which caused an increase of pain in the head, chiefly behind the ear, and an increase of the affection of the sight to such a degree, that on looking at distant objects she had double vision, and a slight squint of the right eye. On the 12th June a third physician was called in for consultation. There was hereditary predisposition to disease of the brain. Five years previous very acute pain was felt at the junction of the sagittal with the lambdoid sutures, which was removed by the employment of steel medicines (Tinctura ferri acetici setherea), and she continued for two years free from pain. Since the beginning of winter the present affection had become gradually worse, the patient’s face was flushed, and the right side swollen ; the right eye was somewhat smaller than the left, owing to osdema of the lower lid, the skin behind the ear felt doughy, and at the nape of the neck, and over the right shoulder, was swollen, indurated, firm, and could not be raised in a fold. There was induration of the cellular tissue, extending along the whole of the outer side of the upper-arm. Motion of the right leg and arm was impeded. The right eyebrow could not be raised so high as the left, the arm could be moved in any direction, but felt as if burdened by a heavy load, and when the attention was withdrawn, supination took place involuntarily. Motion of the hand was perfect, though there was an unpleasant sensation, as if each joint was swollen. The right leg felt weak, the knee trembled whilst standing, and gave way on walking, especially when rising from her seat ; she took shorter steps with the right foot than with the left, and complained of a gradual diminution of sensation over the whole of the right side ; the sense of touch was less than natural, and the right foot, on treading, felt as if there was a cushion below it. Another peculiar feeling was, that on warm fluids coming in contact with the inner side of the right cheek, a burning pricking pain was felt. A continued pain was experienced behind the right ear, over the mastoid process, where the skin felt doughy: this was benefited by warmth, and aggravated by cold, or by gentle pressure. Her sleep was generally undisturbed ; she was sometimes troubled with hoarseness, and an irrita- tion causing a short, dry, nervous cough. My two colleagues were of opinion that there was some organic disease of the brain. I felt convinced that rheumatism was the cause, the more so, as no direct cerebral symptoms were present. As my view held out some hope, the patient was placed under my care.

 My anxiety was, first to allay the general excitement, and then to employ diaphoretic and discutient medicines. The patient kept her bed for the first eight days, took antimonii potassio- tartras in refracta dosi, iodide of potassium, and afterwards the mineral waters of Franzensbrunn, in Bohemia ; her bedroom was kept at a temperature of 66°, and the right side of the head was covered with cotton- wool. Ist Week. The numbness and feeling of cold were less, and the vision was better ; the swelling of the right cheek had subsided, and along with it the sensation on the inner surface of the cheek, the numbness about the head was less, but the scalp became so very irritable that she could not bear to have her hair combed.

 On the sixth day of treatment she had a severe attack of earache, and acute lancinating pains, extending from the back of the right side of the head to the arm : since the profuse perspirations she had enjoyed more mental tranquillity, and occupied herself with reading and writing. On increasing the quantity of the Franzensbrunn waters she suffered from excitement and headache ; her head felt hot, and the perspirations decreased, so that she was obliged to return to the same quantity as before. A pediluvium and medicine allayed the excitement ; the disposition to perspire was unusually great, and was very agreeable to the patient. A.ih Week. Patient discontinued the Franzensbrunn waters and took warm baths. 5th Week. Her arm, shoulder, and leg were covered with oil-silk: this produced a papular eruption, which was very slight over the induration. 6th Week. The patient could see very well, the hoarseness was not quite removed. The scalp was tender and numb behind the ear. The shoulder felt free, the arm much the same, and the foot stronger. 7th Week. Menstruation natural, but great lassi- tude was felt during its continuance. Sth Week. The electrical treatment was resumed. The patient could walk better. lOth Week. The numbness of the scalp was gone, except in a small spot over the lambdoid suture ; the neck was free, and the voice clear. \2th Week. I ordered salt-water vapour-baths to be taken daily for 20 minutes. Patient continued to improve, had no pain, the numbness of the right side was gone, except in a few small spots behind the ear, on the top of the shoulder, and in the finger-ends. \Qth Week. The same treatment was continued; the use of the right hand was restored. She now took out-of-door exercise. 20th Week. The patient complained of nausea; the iodide of potassium was discontinued. I now ordered Dec. Dulcamarse io ter die. 22nd Week. The patient caught cold, lancinating pains returned in the face and behind the ear, the right lower eyelid was oedematous, the hand felt heavy, and the right foot was weaker, and she had also neuralgia costalis: these symptoms yielded in a few days to the treatment employed. 24^A Week. The patient now only complains of a slight sensation of numbness behind the right ear, and a feeling of weight on the shoulder, where there still remains an indurated place. I have no doubt a few weeks more will suffice to remove all traces of her former complaint.]

XVII.— HEMIPLEGIA RHEUMATICA OF THE LEFT SIDE

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 XVIII. HEMIPLEGIA EHEUMATICA AND INDURATION

EXTENDING OVER THE RIGHT SIDE

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III.— RHEUMATIC AFFECTIONS OF THE FACE-PROSOPALGIA

[We now come to those cases in which single parts or nerves are the seat of the rheumaticaffection. The face is the most exposed, and, therefore, most frequently affected ; generally,the parts supplied by the facial branches of the fifth pair of nerves; nerves of sensation. Thetorture occasioned by this dreadful affection is sometimes excessive. The sufferers speak of itas anguish that is scarcely endurable, and you see, in their quivering features and restless limbs, that the acute bodily pang is, indeed, hard to bear.These affections may continue for years, and appear in three forms, viz., pain, paralysis, andspasmodic contractions of the muscles of the face. The fact that there exists so great a numberof specific remedies for these complaints, each of which has been known or supposed to accomplish a cure, affords one of the strongest evidences of the intractibility of the disease.]

XIX.— RHEUMATIC TIC DOULOUREUX

[Mr. F., aged 30, consulted me on the 1st July, 1841. Three weeks previous he had caught a severe cold, and had since been suffering from rheumatic pains in the head and face, which at first were very violent, especially in the night, but during the last few days had decreased. I found the left side of the face pufiy ; the skin could not be pinched up in a fold ; and the cheek sometimes turned red. I applied a gentle electromagnetic current for a short time to the affected side, which immediately removed the pain, but there was a slight return of it towards the evening. 2nd. Patient had had a quiet night, and the trifling pain he felt was removed by another application. Patient was quite free from pain, and dis- continued coming.]

XX.— RHEUMATIC PAIN IN THE COURSE OF THE FACIAL

BRANCHES OF THE FIFTH PAIR OF NERVES

[Mr. N., 60 years of age, a strong robust man ; his general health had been good. Three months previous to consulting me, he was travelling in very stormy weather, and a few days afterwards felt a burning sensation on the left side of the nose, which soon increased to intense pain ; and for the last six weeks caused dreadful agony in the parts supplied by the three branches of the fifth pair of nerves. 5th July, 1842, he consulted me. The side of the face was slightly swollen ; the lower eyelid was of a bluish-red colour ; and the skin about the eyebrow, malar bone, canine fossa, and upper lip was firm and indurated. The internal canthus of the left eye was redder than natural, as also the skin below the left nostril. Firm pressure over the whole of the left side of the face caused no pain, but a light touch brought on paroxysms of violent stabbing pain, darting from the point touched to the eye and the top of the head. These pains occurred with great intensity on blowing the nose, and on eating. At night he was generally free from pain, but paroxysms were brought on during sleep, through turning in bed, and touching the left side of the face, or by the tongue coming in contact with the palate ; the pain caused a copious flow of tears. Patient was not so much reduced as might have been expected from his long suffering. I applied for three days a weak electro-magnetic current. After the first application the pain did not extend so much to the adjacent parts. Qih. The oedema of the lower eyelid had subsided. 7th. The induration over the malar bone was as large as a shilling ; the pain remained away for a longer period, was less intense, and more limited. ^th. The induration was absorbed ; patient had no pain, and it was not induced, as before, by eating, &c. He has since remained well.]

XXI.— RHEUMATIC PAIN IN THE COURSE OF THE

BRANCHES OF THE FACIAL NERVE

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 XXII.— RHEUMATIC PAIN IN THE INFERIOR MAXILLARY

BRANCHES OF THE FIFTH PAIR OF NERVES

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RHEUMATIC FACIAL PALSY*

We now come to facial palsy, which is accompanied by rheumatic effusion into the cellular tissue, and is confined to the branches of the facial nerve. Formerly these cases were considered as arising from apoplexy, until Sir Charles Bell showed thatthey arose from the functional disturbance of a single motor nerve. This view is now too frequently adopted as the correct one in every case ; but as it has been observed that facial palsy is sometimes caused by organic disease of the brainor of the facial nerve, or of the canal through which this nerve passes, this complaint must not invariably be treated as simple peripheric disease of the nerves, which it would be if Sir Charles Bell’s theory were always adopted. From the present state of our knowledge we must admit that facial palsy may be the consequence of an apoplectic hemiplegia, or of some organic disease of the facial nerve, or of the canalis Fallopii ossis temporum, or of (and this most frequently) rheumatic paralysis of those muscles which are supplied by the facial nerve. We will leave for the present undetermined whether we shall consider facial palsy as a pure neuralgic affection or as a peripheric disease, beginning with rheumatic effusion into the cellular tissue, which then acts as a cohibition to the motion of the muscles, or of the function of the nerve which passes through the effusion. I have always observed that the induration of the cellular tissue is not only invariably present in facial palsy, but that it also bears an exact relation to the degree of the paralysis •, and that the muscles have not lost their contractility from the want of the vis nervosa, as in apoplexy, or from destruction of the root of the nerve, but from the diminished contractility of their own fibres. This is exemplified in apoplecticparalysis by the electric current always producing violent contractions, whilst in facial palsy it causes at first no contraction. If we consider the effusionto be the cause of the cohibition, those remedies which produce more active absorption are clearly indicated. Experience has taught us that pure nervines, and particularly strychnia, is useless in facial palsy. Recent cases are often cured in 8-14 days by powerful diaphoretics and external derivatives ; but when the disease has become chronic, it is well known to be very difficult of cure, and inmost cases is not relieved by such means. The treatment I adopt consists of the application of electro-magnetic currents, friction, warmth, and the inunction of the ung. iodinii comp. : the following cases will prove that a favourable result may be looked forward to with confidence

* Dr. Golding Bird remarks in his Lectures : — ” Paralysis of the portio dura is a not unfrequent affection, and I dare say it has fallen to the lot of my auditors to be called to cases of this kind after the patient has been bled, cupped, blistered, mercurialised, and his health and constitutional power shattered by such unnecessary treatment, — a treatment for which the most profound ignorance hardly aifords an excuse. The history of the cases is sufficiently intelligible. A person previously in health exposes one side of the face to a little draught of air, as by sleeping near a window having a broken pane, or travelling in a railway carriage with a half-open window. The result of this is more or less pain and stiffness in the side of the face, followed soon by paralysis of the facial nerve. In such cases the stimulus of electricity remarkably aids the cure : I say the stimulus of electricity, because in such cases it appears pretty certain that the agent in question acts merely as a local excitant, stimulating the paralysed muscular fibres, and arousing their normal irritability, and once more placing them under the dominion of the will.” — Ed.

XXIII.— FACIAL PALSY AFFECTING THE RIGHT SIDE

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 XXIV.— FACIAL PALSY AFFECTING THE LEFT SIDE

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 XXV.— RHEUMATIC PARALYSIS AFFECTING THE RIGHT SIDE OF THE FACE

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 XXVI.— FACIAL PARALYSIS AFFECTING THE RIGHT SIDE

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 XXVII.— FACIAL PALSY AFFECTING THE EIGHT SIDE

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 III. c— SPASMODIC CONTRACTIONS OF THE MUSCLES OF THE FACE

[We now come to a complaint which would seem to be the very reverse of facial palsy, and which is not only accompanied by rheumatic effusion, but is also treated in the same manner. I refer to the spasmodic contractions or twitchings, so often met with in the muscles supplied by the facial nerve. The mildest form, and what constitutes the first symptom of the complaint, is the vibration of single fasciculi of the orbicularis palpebrarum muscle. A cold or a rheumatic toothache has generally preceded these slight twitchings, in which case they form a sympathetic nervous symptom. Sometimes we find they extend from the eyelids to the ala nasi, upper lip, corner of the mouth, chin, and forehead ; when they become an extremely obstinate affection, often continuing for years and resisting every form of treatment. The twitching of the eyelids is very obstinate and annoying; there is generally at the same time slight oedema of the lower lid. In every case where these twitchings have not been confined to the eyelids, I have always found induration of the cellular tissue. This it was which led me to the conclusion that rheumatism was the cause ; for chronic rheumatism appears in the form of pain or of paralysis, and this affection also appears either as paralysis or as an increased irritability of the muscles. In the cases which have come under my observation, the affection was attributed to taking cold ; I therefore directed my treatment to pro- mote the absorption of the effusion, and the result has confirmed the correctness of my view.

XXVIII.— CHRONIC CHOREA OF THE LEFT SIDE OF THE FACE

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XXIX.— CHRONIC CHOREA AFFECTING THE LEFT SIDE

OF THE FACE

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 XXX.— CHRONIC CHOREA IN THE FACE

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 XXXL.—CHRONIC. CHOREA AFFECTING THE LEFT SIDE

OF THE FACE

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IV.— RHEUMATIC PAINS IN THE OCCIPUT

AND NAPE OF THE NECK

[We will now proceed to those cases in which the rheumatic affection is seated in the occipital nerves. This affection is generally very obstinate and unyielding, and is not only met with in the form of pain, but the motor functions are also frequently impeded. This occurs principally when the complaint has become chronic ; and sometimes there is partial paralysis of the muscles of the neck, constituting paralysis agitans, which is very often brought on by rheumatism.]

XXXII. RHEUMATIC PAlNS IN THE HEAD

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XXXIII. ACUTE LANCINATING PAINS IN THE OCCIPUT

AND BACK OF THE NECK

[W. H., 48 years of age, a carman, had suffered for 12 years, without intermission, from very acute, shooting, and throbbing pains in the scalp and upper part of the neck. They varied in severity, being most acute in windy weather ; were felt less when the atmosphere was dry and cold, and least of all during the heat of summer. Seven years before the patient had consulted me, his digestive organs being also deranged, he was ordered purgative medicines, the muriate of ammonia, in halfdrachm doses, dissolved in water, three times a day, and warm baths : this treatment mitigated the pain and removed the disposition, which followed each irregularity of diet, to increase the pain to perfect agony, which always continued from 8 to 14 days. Two years afterwards he again consulted me, the agony of his sufferings obliging him to relinquish every occupation. I advised him to take Russian vapour-baths, and to apply mustard poultices over the seat of pain :he derived but little benefit from this treatment, the pain always increasing to the same intensity in damp and cold weather. In the winter of 1841—42 he again consulted me. I advised him to try blisters, mustard poultices, and vapour-baths ; but these obtained him no release from his excruciating and maddening suflerings. The muscles of the head and neck were rigid and contracted the skin felt firm, indurated, and as though it were adherent to the bone at the back of the head and over the forehead. The pain always became worse towards evening, depriving him of sleep j it passed from the temples to the forehead, and remained fixed at the top of the head, which he was obliged to bend forward and keep motionless, with his eyes half closed. I advised him to take a warm bath every other day, and applied an electro -magnetic current to the parts affected. At first the pains remained away only for an hour at a time ; but the interval became gradually longer, and they diminished proportionably in severity until an entire removal was effected. In three weeks the muscles of the head and neck and the skin had regained their natural condition, except a small place in the forehead, which was very slowly acted upon : when this place was removed, the patient was quite free from pain. In March, 1842, the patient, when out in the cold easterly winds, had attacks of shooting pain in the head, which ol. sinapis ^thereum solutum in spirit, ten. rubbed over the place took away ; or, if this failed, one application of the electro-magnetic current was quite sufficient.]

XXXIV. RHEUMATIC PAINS IN THE HEAD AND NECK

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 XXXV. ACUTE RHEUMATISM FOLLOWED BY INDURATION OF THE CELLULAR TISSUE AND IMMOBILITY OF THE UPPER-ARM AND NECK

 XXXVI.— RHEUMATIC PAIN AFFECTING THE WHOLE OF THE ARM*

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 XXXVII.-RHEUMATIC PAIN IN THE SHOULDER

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 XXXVIII.— RHEUMATIC INDURATION OF THE RIGHT ARM

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XXXIX.— RHEUMATIC INDUEATION OF THE RIGHT

SHOULDER

[H. W., a bricklayer, 54 years of age, an old-looking man,had been suffering for the last eighteen months from shooting rheumatic pains in the right shoulder and upper-arm. These were constantly felt, but were most acute during the night. He had tried all descriptions of baths, and a number of other remedies, without experiencing any relief. When I saw him, he had been eleven months in the Charite Hospital. He could not raise his right elbow higher than the nipple, and lifting it so high was attended with considerable pain; neither could he put his hand behind him, and he was quite incapable of doing anything for himself. The cellular tissue of the shoulder and upper-arm was indurated and painful on pressure, from the posterior border of the deltoid muscle to the lower half of the biceps, and from the upper border of the trapezius to the claviculo-acromial articulation.

The patient perspired freely, but where the induration extended this was not perceptible. I ordered electro-magnetic currents to be applied. He felt relieved after each application, and was able to raise his arm without inducing an attack of pain ; but after a few hours this improvement passed off, and his sufferings, especially in stormy weather, became most acute. The electro-magnetic currents were applied with great regularity for three months. In the 4th week of the treatment, the induration over the anterior border of the deltoid muscle commenced to decrease: this enabled the patient to touch his left shoulder. In the 6 th week, the induration over the trapezius decreased, and the patient was able to raise his hand to the top of his head and to the left ear. After ten weeks the whole of the induration was completely removed, and along with it the pain and obstruction in using the limb : the patient was discharged cured. On seeing this patient, six months afterwards, he told me that he had had no return of pain, and that his arm was as strong and useful as ever.]

 XL.— LOSS OF POWER AND RHEUMATIC INDURATION OF THE UPPER ARM

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 XLII.— RHEUMATIC PARALYSIS AND PAIN AFFECTING THE LEFT SHOULDER

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 XLIII.— RHEUMATIC PARALYSIS OF THE UPPER-ARM

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 XLIV.— RHEUMATIC PARALYSIS AND ATROPHY OF THE

RIGHT ARM

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 VI.— THE WRITER’S CRAMP*

 XLV.— THE WRITER’S CRAMP

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 VII.— RHEUMATIC PARALYSIS OF THE FORE- ARM

 XLVIL— ATROPHY OF THE MUSCLES OF THE FORE-ARM

AND HAND

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XLVIII— RHEUMATIC PARALYSIS AND ATROPHY OF THE

EXTENSOR MUSCLES OF THE HAND AND FINGERS

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L.— RHEUMATIC PARALYSIS OF THE EXTENSOR MUSCLES OF THE RIGHT HAND

 [M. S., 26 years of age, a servant girl, left her bedroom window open all night, and the next morning felt acute pain in the right wrist, extend- ing up to the shoulder. The medical man she went to advised her to apply cold-water dressings to the wrist, which for a short time alleviated the pain, but in the night it returned with increased severity. The next morning there was a bright red shining swelling of the hand and fore-arm.The patient was admitted into the Charite Hospital. The acute stage was removed by bleeding, warm fomentations, saline and diaphoretic medicines, but the patient had frequent attacks of pain in the shoulder and upper-arm, and the extensor muscles of the hand were palsied. When the fore-arm was extended, the hand hung down, forming a right angle with the arm. The cellular tissue over the deltoid and origin of the supinator longus muscles was indurated and painful, and at the back of the fore-arm felt thickened. l5^ September. The treatment now employed consisted of warmth, diaphoretic medicines, and the daily application of a powerful electro-magnetic current, which after being employed a few times removed the pain. 6th. The cellular tissue began to soften, andean passu the extensor muscles of the hand gradually regained the power of motion. Each application was followed by evident improvement, so that, on the 16th, the patient was discharged cured.]

LI,— PARALYSIS OF THE EXTENSOR MUSCLES OF THE HAND

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LII.— RHEUMATIC PARALYSIS OF THE RING AND LITTLE

FINGER, AND INDURATION OF THE CELLULAR TISSUE

ALONG THE INNER SIDE OF THE FORE-ARM

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 LIII.— RHEUMATIC PARALYSIS OF THE THUMB, FORE

AND MIDDLE fingers OF THE RIGHT HAND

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VIII.— MUSCULAR RHEUMATISM IN THE BACK

LIV.— RHEUMATIC PAIN IN THE BACK, AND MUSCULAR INDURATION EXTENDING DOWN THE BACK

[Charles F., a peasant, 26 years of age, thick set, and very muscular, suffered, in the winter of 1841-42, such acute pain in the shoulders and back, as to be obliged to leave his employment. On the 25th February, 1842, he was brought to me. He walked very stifily : sitting down brought on violent pain, and he complained of acute lancinating pain in both shoulders. The back was bent forwards, and stiff”: there was on either side of the vertebral column a peculiar hardness of the muscles, which felt like cords, and on pressure, the muscles slipped away and crepitated. The skin about the shoulders was stiff^ and could not be moved about over the parts beneath. The back and both shoulders were daily electrified. The pains in the shoulders were quite removed, after the fourth application. 1st March. The loins were now daily electrified. 7th. The shoulder joints were both quite free ; the back was not so stiff; the muscles felt softer, but the creaking noise in the lumbar muscles continued. lOth. The patient could move about, stoop, and raise himself up again without any feeling of pain. The creaking noise alone remained, and that was much diminished. I2th. The patient was discharged cured.]

LV.— LUMBAGO

[Peter D., a tailor, 43 years of age, general health pretty good, had in 1840 the typhus fever, from which he quite recovered. In the winter of 1840-41 he occupied a large cold room, and eight weeks before I saw him, was attacked with pain over the sacrum, and lancinating shooting pains in his bones, felt especially at night, when in bed. He was unable to stoop ; was obliged to walk very care- fully, and looked ill from the want of rest. 2’^th Aprilj 1841, a current of electro-magnetism was applied for the first time 5 the next day he had no pain in the sacrum. ^Otli. The patient moved about better, and was free from pain. ^rd May. Had only a little difficulty in stooping. 9^/i. The patient was discharged cured. In the middle of June he came to me, and complained of pain over the crest of the left ilium. An electro-magnetic current was applied eight times, galvano-puncture was then employed which immediately removed the pain, and at the end of a fortnight he was discharged cured].

 LVI.— RHEUMATIC PAIN IN THE HIP

[F. W. S., 37 years of age, a serjeant in the artillery, and who had been nine years in the service, caught cold two years before when encamping in wet weather on the occasion of a review, and had since been subject to chronic rheumatic pain in the left hip and foot : he was unable to walk without the assistance of a stick.

A current of electro-magnetism was applied daily for three weeks. 20i/i June. I made galvano-puncture, which directly freed him from pain. ‘2bth. He felt a slight pain in the right hip, which yielded to galvano-puncture. 2Qth. The pain was very acute, but continued only for half an hour. 28^A. The patient could not exactly say where the pain was. bth July. He was discharged cured.]

IX.— RHEUMATIC PAIN IN THE HIP

LVII.— SCIATICA

[Mr. S., 40 years of age, healthy, but had often had rheumatic pains induced through riding in wet weather ; consulted me on the 22nd December, 1841. Two months before this he had a very acute attack of pain in the loins which continued for four weeks. For a month past he had used Russian vapour-baths, which afforded him some relief, and removed the pain from the loins to the left thigh. During the last few days the pain was aggravated by sitting or walking for any length of time, which he did with difficulty even with the aid of a stick. On examination I found that pressure over the trochanter major was very- painful. As is usual there was a great increase of pain in the night, so that he had but little sleep, and appeared worn out in consequence. I advised galvano-puncture, which he would not consent to have applied. I therefore employed the electro- magnetic current in the usual manner. Isf January. I had applied the current eight times; the pain was removed after each application, and the nights were free from pain. The pain returned on sitting or walking for any length of time, but with less severity. Wih. The treatment was resumed. The patient now desired to try galvano-puncture. The immediate relief was highly gratifying ; he was free from pain, the leg felt stronger, he could lift it better, and pressure was not painful. Every trace of pain was removed. After the 14th application of the electro- magnetic current, the patient felt quite well, and discontinued coming. I have since seen him, he has had no return of pain.]

LVIIL— SCIATICA

[A young Swede, attache to the embassy of Berlin, 27 years of age, had lived very freely, and been salivated several times. He had been subject to sciatica for the last few years. 1th January, 1842. He had another attack, for which he applied blisters, mercurial and narcotic ointments, and used 60 Russian vapour-baths without any beneficial effect. Every morning on getting up he felt very acute pain in the course of the left ischiatic nerv e,which gradually decreased and subsided entirely by the evening, leaving a feeling of weakness in the left leg, and causing him to limp. On going to bed, acute pain was felt, which continued for one to two hours, and then ceased until 9 a.m. Being obliged to leave Berlin in eight days, the patient was willing to submit to anything through which he might obtain relief. 23?^cZ April. The patient called on me. I could not find any induration either about the left hip or thigh, but deep in the posterior third of the great sacro-ischiatic notch there was a firm elastic swelling which was painful on pressure, and on the posterior surface of the thigh there was a spot as broad as two fingers, which was always cold and painful on pressure. The patient complained of very acute pain in the left hip when sitting or walking. The leg felt very weak, and as if it would give way from under him when standing. I inserted a platina needle connected with an electro-magnetic apparatus through the skin close to the posterior superior spinous process of the ilium, and another over the place which always felt cold. The application was continued for 10 minutes, and gradually increased in strength, which removed the pain and weakness felt in the foot, and the patient was able to walk without the use of a stick. A slight pain returned after three hours, and continued during the night. 2bth. The night was free from pain,” which was also much less on walking, and, after the application of a current, remained away for the whole of the day. 28^A. The pain was very trifling in the morning, subsided after the application of a current, returned in the afternoon, and continued for the remainder of the evening. 30^/i. The patient said that he had been quite free from pain the whole of the previous day, and nearly so that morning, and had perceived no sensation of cold in the thigh for the last two days ; the application of the electro-magnetic current completely removed the pain and weakness. 1^^ May. The patient felt only a little pain on rising. He had walked a long distance the day before, and that morning without feeling any ill effects. 2?2cZ. The patient left Berlin. Whilst under my care he took a bath of aromatic herbs daily. We cannot explain the periodical return of rheumatic pains, and equally singular is another form of pain frequently met with as affecting the hip, which also seems to be caused by rheumatism, though I have never been able to discover any induration. In the cases I allude to, the pain on rising from the sitting posture is so acute in the hip and knee, that the patient is scarcely able to move, even with the help of his hands, but the more the limb is exercised the quicker the pain subsides.]

LIX— SCIATICA

[Mrs. Z., 50 years of age, very corpulent, occupied a cold damp dwelling, and had suffered for the last six years from sciatica, and a fixed pain in the right hip and knee, which on rising from her seat, and on walking, became very severe. The patient suffered at night violent shooting pain in the right limb for weeks together, which prevented her obtaining any sleep ; cold damp weather always brought on an attack. I applied galvano-puncture for three weeks, one needle being inserted over the hip, the other over the knee. The nocturnal pain was completely removed, but that felt on rising still continued. The patient discontinued coming.]

LX.— SCIATICA

[Mrs. L., 54 years of age, robust and very corpulent, had suffered since the previous winter (about five months) from sciatica, which was always more painful in damp weather, and very acute at night. On rising from a chair, she was obliged to support herself for some minutes before she could take a step, on account of the pain in her hip and knee. From the 24th May to the 14th June, galvano-puncture was made daily. The nocturnal pain, and also that in the knee was removed ; the pain in the hip immediately after the application of the electro-magnetic current, was less, though on the whole, not much improved. The patient discontinued coming.]

 LXL— SCIATICA

[Charles P.j 50 years of age, a locksmith, came to me on the 30th May, suffering from sciatica, which had been so acute for the last seven weeks as to deprive him almost entirely of sleep, and he was compelled to leave his work from the pam being increased by standing. The skin, from the crest of the ilium to the middle of the thigh was indurated, cold, and of a whitish colour. The patient had never felt pain in the joint. A pain began at the crest of the ilium, and passed to the groin ; but that which was the most acute passed downwards behind the trochanter to the outer side of the knee, and extended sometimes, when very severe to the dorsum of the foot. A very powerful current was applied to the surface. 1st June. The pain had ceased during the night, and intermitted in the day; the indurated skin felt softer, had a more natural colour, and on the application of a powerful current, was covered with large red spots. 3rd. The pain became worse after a thunderstorm, and spread to the right hip and to the back. The fact of the pain moving about, was a favourable sign. The induration was quite absorbed. bth. The patient had had no return of pain for the last 24 hours, and wishing to go to work again, he discontinued coming.]

LXI I. —SCIATICA

 [G. M., a Russian, 44 years of age, a valet, had enjoyed very good health, until within the last eight years, when from frequent colds he had an attack of rheumatism. He had been subject to attacks of sciatica for the last three years, which continued for months at a time. In January, 1841, he had an attack of sciatica, which continued in spite of medical treatment, until the middle of summer, when he went to Doberan, and took sea baths, which freed him from it. In the beginning of October he returned to Berlin, and at the end of November, the complaint returned in all its former severity. Blisters, leeches, Russian vapour-baths, salt-water baths, colchicum, anodynes, &c. were employed, but without benefit ; the pain continued unabated, and underwent violent exacerbations. The patient was very much reduced, and the complaint gradually assumed the character of a pure nervous affection. On the 20th April, 1842, his medical attendant advised him to consult me. His countenance bore the expression of acute suffering, from the loss of sleep for so long a time ; he was exhausted and emaciated ; he walked with great difficulty, even with assistance ; took very short steps, did not lift the left foot, held his knee quite stiff and bent backwards. Every movement was made with anxious care, particularly any which required the abduction of the left thigh. He complained of a violent pain which passed down the left thigh to the knee and external malleolus, and which became at night dreadfully excruciating ; rising from his seat was a dreadful punishment, and, of late, the least excitement or speaking quickly, brought on severe paroxysms of pain. I immediately observed the great difference in the size of the two legs 5 and that the most severe pain began, about three inches below the trochanter major, and passed inwards right through the thigh. Another acute lancinating pain followed the course of the ischiatic nerve, involving sometimes the whole of the outer side of the leg to the dorsum of the foot. He described the pain as resembling a piece of the skin being laid hold of with pincers, and torn off. He had acute shooting pain in the gracilis muscle, and down the outer side of the thigh, and also a disagreeable sensation of cold and numbness, of which he complained greatly, being obliged to rub this part with flannel every night for three or four hours. The skin from the trochanter to the lower third of the thigh was thickened, indurated, white, cold, and shining. This swelling was distinctly perceptible to the touch, and also marked by the dift’erence of colour over it ; there was loss of sensation ; pressure was slightly painful, and the vastus externus muscle felt dry and atrophied. A fold of skin could be pinched up, but it felt hard and cartilaginous. I advised the application of the electro-magnetic current, aromatic baths, and every other application to be discontinued. ^Oth April. After the current had been applied for half an hour, the patient felt relieved, the cold feeling in the knee was removed, and he could move the thigh without bringing on pain, the skin of the thigh glowed in the course of the afternoon, and he passed a quieter night than he had for months. 2lst. The pain shifted its seat. 29th. The patient was quite free from pain ; he complained of a feeling of weakness in the leg, and of coldness in the knee. The induration of the skin of the thigh was a little softer, and remained white and smooth, whilst the other parts reddened, and cutis anserina was produced by the application of a powerful current. 30th. The patient had an attack of pain, but it lasted only for a short time. He improved daily. Srd Week. He was generally free from pain during the day. It came on towards evening, and subsided on getting into bed ; the sleep was seldom disturbed. In the morning a slight pain was felt in the hip, which the electro-magnetic current removed for the remainder of the day. The indurated skin became turgid on the passage of the electro-magnetic current. Above the trochanter major I felt a deeply-seated induration (a rheumatic node) which was painful on pressure, and from which the pain seemed to proceed. 13^^ MaT/. I employed galvano-puncture over this spot and to the knee. 7th Week. The induration of the skin rapidly decreased, and the node appeared more distinct. 3rd June. We had a violent thunder-storm which increased the symptoms of my rheumatic patients ; the pain was felt for several days more acutely in the hip. 9^/^ Week. The skin about the ankles felt as if it were being pinched up and torn off, pain comes on in momentary paroxysms. I2th Week. The induration of the skin was quite gone, the rheumatic node was also softer. 7th July. The patient had a momentary attack of pain this morning, when his former medical man happened to call upon him, and advised (without consulting me) a blister to be applied to the thigh immediately, and cod’s liver oil to be taken. I, therefore, declined having anything more to do with the case. 27th. The patient sent for me again. He had had a great deal of pain since I last saw him, and the skin on the outer side of the thigh was again indurated ; he was much alarmed by the loss of power of motion and stiffness of the muscles which had supervened. The nights were sleepless. A current diminished the pain and procured a quiet night. There was slight inflammation about the node, and on the 30th July and 5th August I ordered six leeches to be applied. I4th August. The patient was nearly free from pain : the debility felt in the muscles of the thigh continued. In consequence of my going into the country the treatment was discontinued, and on my return I found that the patient had left Berlin.]

LXIII. -SCIATICA

[Mr. L., 32 years of age, had enjoyed excellent health. He told me that formerly he had a florid complexion, but from the constant pain and loss of sleep he had become thin and pallid. In October, 1840, he caught a severe cold; since which he had suffered without intermission from sciatica in the right side. All this time he had been under medical treatment, but every remedy tried had proved ineffectual. He took the Dec. Zittmanni lor a month with some benefit, but was never entirely free from pain. Stramonium and other remedies were inert. Dr. Schoenline advised him to take spirits of turpentine, which removed the pain in the hip •, but he was then seized with vertigo and violent pain in the head ; this yielded to vapour-baths, when the pain in the hip returned and had since been continuous. On walking fast the pain diminished, but increased on walking slowly or standing. It was very severe on rising from a sitting posture, and he suffered exacerbations during the night, each lasting from one to two hours, and increasing in stormy weather. In consequence of the nocturnal pain, the patient was debilitated, he dragged his leg and took short steps in walking. 2’Srd January. He came to me accompanied by Dr. Schoenfeld. I observed 1|- inches above and behind the right trochanter a painful spot on pressure. The pain spread from this spot over the outer side of the thigh to the knee, and along the anterior surface of the thigh. When the patient came to me he had a slight pain which caused him to limp. After the application of a current he was free from pain, the right leg felt lighter and stronger, the pain returned whilst on his way home, but again subsided until 7 p.m., when he had another attack which lasted for a couple of hours. He passed a quiet night. 24:th January. On getting up he had a return of the pain which was removed by the electro-magnetic current, and did not return until between 7 and 8 p.m. The night was free from pain. 2bt]i. Slight pain was felt in the anterior surface of the thigh, the induration behind the trochanter was nearly gone. The skin of the thigh had felt warmer for the last two days, and was not so pale. The thigh and hip were powerfully electrified, after which the patient was free from pain and felt stronger. 26^A. The patient had no pain, but complained of a feeling of exhaustion. I advised him to take a warm bath at night. 27th. A slight pain had returned in the anterior surface of the thigh, which was not increased by walking. 30^A. There was scarcely any pain felt in the anterior surface of the thigh, and none on getting up or on walking. 3\st. There was slight pain in the anterior surface of the thigh, which was removed by the electromagnetic current. \st February. A little pain was felt in the leg for a quarter of an hour. ^nd. There was a little pain felt in the middle of the thigh which lasted 15 minutes. I applied the galvano-puncture. Ath. Every trace of the complaint was gone. Qth. The patient continued to feel quite well, and had acquired his former healthy appearance. The treatment was discontinued.]

 RHEUMATIC PARALYSIS OF THE HIP

 Rheumatic induration is of considerable importance in the diagnosis of coxalgia. We frequently meet with pain in the hip-joint, not attended withinflammation, which resembles the symptoms of the first stage of ulceration of the hip-joint. If these cases are treated as inflammatory disease ofthe joint they become worse, but always retain the characteristics of the first stage of ulceration. The principal danger of ulceration — destruction of thejoint — (or, as it is wrongly called, spontaneous dislocation) does not result, the patient limps very evidently, and on walking and change of weather, suffers pain in the hip and thigh. These cases are generally considered incurable, but if the na-ture of the complaint has been understood, and anti-rheumatic treatment is employed, complete recovery is possible. The patient has pain on walking, saves the limb as much as possible, does not rest equally on both feet, inclines his thigh forwards, keeps the foot slightly averted or turned inwards, and stretched out in advance, the knee is slightly bent, and he treads on the heel or the toes. The affected hip is generally pushed more forwards, and the pelvis is more or less twisted. On careful measurement, it will be found that the trochanter on both sides is the same distance from the anterior superior spinous process of the ilium.On pressing the head of the femur against the acetabulum no pain is felt in the hip, perfect extension of the thigh is impossible, and stretching it at all is accompanied by a dull, violent, or slight pain, and it is this symptom which so frequently leads to a wrong diagnosis. The fact that this form of the disease is not attended with destruction of the joint, but exists only as long as the pain continues, has given rise to an attempt to distinguish coxalgia from coxarthrocace. The difficulty of distinguishing the first inflammatory form of coxalgia from the first stage of coxarthrocace, has induced many surgeons to oppose this distinction, for they entertain the opinion that it is better to consider every case as being a different stage of coxarthrocace, than to run the risk of mistaking the first stage, and so facilitate by injudicious treatment, or at least not averting the occurrence of the advanced stage. I consider that coxarthrocace is caused either by a deposit of tubercles in the bone, or arises from caries peripherica, which begins in the synovial membrane, and as far as I have had an opportunity of judging, runs a more chronic course, but still has much resemblance to rheumatic affections ofthe hip-joint, it is therefore of importance to discover some symptom which will enable us to distinguish scrofulous and inflammatory coxar- throcace from rheumatic disease of the hip-joint. Believing induration to be a constant symptomin rheumatic affections, I entertained the hope that it might be the means of distinction in the abovementioned diseases. After a careful examination of several cases of scrofulous disease of the hip- joint, I was satisfied that in them induration of the skin and cellular tissue did not occur. In May, 1841, I had an opportunity of observing in a child aged 7, an affection of the hip, beginning after exposure to the cold •, the patient suffered acute pain on moving the right thigh, could only tread on the toes, limped, and the nates on the right side wasswollen. There was a large, broad induration of the cellular tissue extending from the middle of the ischiatic notch behind the trochanter to the middle of the thigh. The medical man called in recommended leeches, and counter-irritation by means of a moxa. After careful examination, I was convinced that the disease was rheumatic, and proposed a diaphoretic treatment. The patient took small doses of antimonii potassio-tartratis, warm beverages, as lemonade, had a bath of brannight and morning, and was kept in a warm room. The stick with which he had already learnt to move about was taken away, and he was not allowed to keep his bed. The result was most satisfactory. The first night the patient was in a profuse perspiration, and the next day could tread on the heel ; the third day he was able to walk alone, though he still limped very much, and the induration of the cellular tissue had decreased. The child perspired very freely on the ninth day,was free from pain, and the induration was absorbed. I advised that he should wear flannel next his skin. I saw the child in 1812 ; the complaint had not returned.

LXIV.— PARALYSIS OF THE THIGH

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LXV.— RHEUMATIC AFFECTION OF THE MUSCLES OF THE HIP AND THIGH–

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LXVI.— COXALGIA. INDURATION OF THE CELLULAR

TISSUE BEHIND THE TROCHANTER MAJOR

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XI.— RHEUMATIC PARALYSIS OF THE MUSCLES OF THE THIGH

LX VII.— RHEUMATIC PARALYSIS OP THE ADDUCTOR

MUSCLES OF THE THIGH

XII.— RHEUMATIC AFFECTIONS OF THE KNEE

LXVIII.— RHEUMATIC SWELLING OF THE KNEE

[Miss A., 18 years of age, fair, healthy-looking, and had always enjoyed good health, had, in 1841, an attack of acute rheumatism in the left knee, which was combated by leeches, cupping, blisters, calomel and opium, and stimulant and discutient applications, &c. Convalescence was very slow; and when the patient consulted me, on the 4th July, 1842, she could only walk a very short distance, suffering severe pain. The knee was swollen, from an enlargement of the internal condyle of the femur and head of the tibia, and from fluid in the joint, which could be felt on either side of the ligamentum patellae. The leg was ex- tended and almost motionless ; in fact, there was merely suflScient movement to allow me to ascer- tain that anchylosis had not taken place. Pressure made over the internal condyle of the femur was slightly painful, and when made on the popliteal space showed that the tendons of the flexor muscles were rigid and contracted. The patient said that she had not slept for the last two nights on account of violent shooting pain in the knee and shin. Electro-magnetism was at first alone employed. Directly after the application the left leg felt lighter, the shooting pains ceased, and the pain felt on walking was less. 2nd Week. The patient could walk a long dis- tance, and the pain did not return for one or two hours, and again subsided after a little rest ; the elastic swelling on either side of the ligamentum patellae was gone; there was a sharp prominent edge and several round lumps felt over the internal condyle of the femur and the head of the tibia. 3rd Week. Electro-magnetic currents and ung.iodinii comp. were applied to this part. 4th Week. There was slight voluntary motion in the knee. Currents were daily applied. 5th Week. The swelling about the internal condyle had lessened. 6th Week. The patient had taken several long walks without feeling any pain. The edge of the internal condyle of the femur was quite smooth. 7th Week. Passive motion of the joint was daily employed with great care to a considerable degree without inducing an attack of pain, though a few weeks back the most careful attempt at passive motion caused the most dreadful pain. The patient was desirous, in order to accelerate her recovery, that the tendons should be divided. This I objected to do, as, in consequence of the enlargement of the bone near the surface of the joint, it would have been but of little benefit. The same treatment was continued for a short time when, on account of the patient being compelled to leave Berlin, it was discontinued.]

 LXIX.— RHEUMATIC SWELLING OF THE KNEE

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LXX.— ACUTE PAIN IN THE KNEE-JOINT.

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LXXI— SWELLING OF THE KNEE, AND INDURATION OF THE CELLULAR TISSUE

 [Mr. G., a sculptor, consulted me on account of his knee : he had always enjoyed good health. In February, 1842, he suffered constantly from catarrh through exposure in a cold attelier, the floor of which was of stone. All the winter he had suffered from lancinating pains in his limbs ; and in February he had acute rheumatism in the right knee. On the 10th August, when I was consulted, the right knee was a little swollen ; the skin was thicker and adherent to the indurated cellular tissue below ; he complained of a stabbing pain felt on standing and walking, which was very nmch increased by fatigue. The pain extended to the dorsum pedis and to the hip. After the appli- cation of a current of electro-magnetism, the foot felt lighter and stronger, and the pain in the hip was removed. I2th, The elastic swelling was gone, and the pain was felt less after walking. \3th. The skin over the knee was softer, and the knee felt much warmer. I7th. The pain in the knee was quite gone, and the skin was softer and freer. That in the loins was removed by galvano-puncture applied twice on successive days. The induration of the cellular tissue about the knee diminished every day, and in the same proportion did the stiffness of the joint wear off. The. patient was now attacked with typhus fever, after his recovery from which the knee was quite well]

XIII.— RHEUMATIC PARALYSIS OF THE MUSCLES OF THE LEG

LXXII.— PARALYSIS OF THE EXTENSOR MUSCLES OF THE FOOT, AND INDURATION OF THE CELLULAR TISSUE

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LXXIII.— PARALYSIS OF THE MUSCULI PERONiEI, AND

INDURATION OF THE CELLULAR TISSUE EXTENDING

OVER THE OUTER SIDE OF THE LEG

 XIV.— RHEUMATIC PAINIIN THE SOLE OF THE FOOT

LXXIV.— RHEUMATIC PAIN IN THE BALL OF THE FOOT

[H. S., 40 years of age, a bricklayer, a tall, powerful, and healthy-looking man, was seized in September, 1841, with lancinating pain in all his joints, accompanied with slight febrile symptoms, which soon passed off; but the pain continued very violent. He was admitted into the Charite Hospital ; and from the treatment employed, the pain ceased in all the joints with the exception of the feet, in which, for the last three weeks, he had endured great suffering. bth April, 1842. I was consulted. He walked with great difficulty, as each of the ankles brought on excruciating pain. The metatarsal joint of the left great toe was swollen, of a bluish-red colour, and very painful on pressure. After the first application of the current he had no return of pain during the night. Ath Day. The blue colour and swelling of the left foot had decreased. ^nd Week. The pain in the ankle joint was quite gone, and was only felt in the ball of the foot and metatarsal joint of the great toe.^rd Week. There was very little swelling of the left foot. The ankle was quite free from pain. Ath Week. The pain continued unabated in the ball of the foot, which had a doughy feeling. After the application of a very powerful current, it was removed for a few hours, but returned with as much severity as before. bth Week. Galvano-puncture was employed to both feet ; one platina needle was inserted near the second toe, and the other at the middle of the inner border of the foot. The result was most successful; the patient was immediately relieved from pain ; the foot felt quite strong ; he was able to walk easily and firmly, and to raise himself on the toes of one foot. The pain remained away until the 3rd June, when, after a thunderstorm, a little shooting pain was felt in the left foot ; and as it continued, the patient came to me on the 5th June. Galvano-puncture was again employed, since which he has continued quite well. He called on me in July to say that he had had no return of pain, and that he was able to carry a hod of bricks up a ladder as well as ever. On the 3rd January, 1843, the patient came to me again, on account of pain and swelling of the first joint of the left middle finger ; there was an elastic swelling about this joint, which was of a bluishred colour, and painful when touched; he also complained of a dead sort of pain in the arm. The finger was nearly straight and perfectly stiff”. 3rd January/. Galvano-puncture was made ; at night the patient bathed his hand in hot lye, and applied a mustard poultice to the swollen joint. 4tk. The pain was removed from the arm ; the finger could be half flexed ; was less painful and swollen: the same treatment. 5th. The pain was quite removed ; the hand felt light, and motion was perfectly free ; the fingers could be bent, but not firmly clenched. The swelling about the finger-joint was gone ; the redness was confined to the ulnar side of the finger, where it was only painful when pressed. The same treatment. 6th and 7th. The treatment was omitted. Sth. The joint was rather more swollen, not red, and only painful on pressure at the side ; he could clench his hand, which was painful when firmly closed. The same treatment. lO^A. The patient could use his hand freely and without feeling any pain : and, at his request, he was discharged. He called 14 days afterwards tosay he was quite well. ]

LXXV.— RHEUMATIC PAIN IN THE SOLE OF THE FOOT

[T. P., 28 years of age, a printer, was attacked in the autumn of 1840, with acute articular rheumatism, which confined him to his bed for several weeks, when it assumed a chronic form ; and he had lancinating pains in his limbs. He was admitted into the Charite Hospital ; and in a short time, the erratic lancinating pain subsided from the treatment employed : sulphur-baths, &c. The heels and soles of both feet remained painful ; he was not able to stand for more than a few minutes at a time, and could not run or go up stairs without suffering great pain. Blisters, stimulant embrocations, leeches, vapour-douches, and sulphur-baths were employed without producing any benefit. The complaint continued unrelieved for some months. lOth July J 184L The cellular tissue of the heels and soles of the feet was indurated and thickened, and there was a swelling below the inner malleolus and at the inner side of the heel, over which pressure was slightly painful. I applied electro-magnetic currents : each application was followed by an improvement lasting for three to six hours, during which time the patient could stand, run, or walk up stairs without feeling any pain. I now applied galvano-puncture three times. After the first application, the pain ceased completely ; and after the thirdapplication, he was discharged cured.]

Published in August 2019 by Marta Cañis Parera