He therefore meter. There is scarcely a sin- pectoral muscle. V. A young woman had, for We cannot conclude the foregoing narrative better than in the writer's own words. "It follows," says he, "from the observations related above, that resection of the ribs is not one of the very dangerous operations, as surgeons have hitherto believed; and that hemorrhage of the intercostal arteries may be checked simply by compression, without having recourse to the ligature, provided they are cut near the sternum, where they are small in dia puration, enduring for months or Rheumatism, and some Diseases of ward as our instructers; and they have met their reward in crowded audiences, and in increase of reputation. We do not mean to draw any invidious comparisons, but it cannot be denied that the College of Physicians have, for the most part, confided the post of lecturer to some one of the junior fellows; and, with the single exception of Dr. COOKE, whose Croonian lectures for 1819 were so favorably received by the public, we do not remember any instance in which the senior fellows have lately put their shoulders to the wheel. We hope to see this altered; and indeed reports have already reached us that some change in this respect may be speedily looked for. We have in our eye at this moment many, physicians, whose experience, could they be induced to give it, would be most gratefully received by a large proportion of the medical public in London; and we confidently predict that, in such a case, the theatre of the new College would be found totally inadequate to the number who would attend. It will probably be a matter of surprise to our country readers, when we inform them that the lectureroom of this magnificent building will with difficulty accommodate a hundred per sons. Though we have been led into this train of reflection from the perusal of the work before us, we by no means wish to insinuate that Dr. HAWKINS was undeserving of the honorable post assigned him. On the contrary, we think that he has produced a volume useful to others and creditable to himself. It shows much learning, and is clearly and neatly put together; but, when we come to analyse it, our readers will perceive that it is chiefly occupied with speculations in pathology, which, though highly ingenious, are not to be compared, in point of value, with the results of experience in the administration of remedies. It is only at an hospital that such a disease as rheumatism can be properly studied; but even here, with every possible attention that can be given by an intelligent physician, many years must elapse before he has made himself conversant with all the varieties of the disease, and qualified himself to speak with confidence on those difficult and recondite points in its pathology and treatment, on which the medical world are really anxious to receive instruction. But it is time that we bring the author of the Gulstonian Lectures for 1826 more immediately before our readers; and this we shall do by giving a succinct view of the subjects discussed in each of the three lectures of which the volume is composed, selecting one or two passages out of each, as best showing the author's style of treating his subject, or as illustrating some point of particular novelty or interest. The first lecture is occupied with speculations on the seat of rheumatism. The author first inquires whether the muscular texture be in any case the seat of this affection, and he argues in favor of such an opinion, from a consideration of the symptoms of rheumatism, the situation of the pain in certain cases, and the alleged appearances on dissection, as described by some foreign writers. The author very candidly states that these arguments are not conclusive, and that they only give a degree of probability to the opinion. We are next instructed that the chief seat of rheumatism is in the fibrous and tendinous structures of our frame. "It is in this quarter that rheumatism makes its most frequent invasions, exerts its most violent and extensive influence, and too often establishes a permanent dominion." We are told that BICHAT was the first to collect these parts under the general name of fibrous tissue. "They are frequently divided into two classes-1. Those which serve to connect parts together; and 2. Those which divide and envelope particular organs. "To the first class belong the tendons and ligaments, and aponeurotic expansions of tendons. "To the second, the muscular fasciæ, or bands, and enveloping aponeuroses; the periosteum; the fibrous coats of the nerves; the membranes which have on one side a serous lining, as the dura mater and pericardium; also the fibrous sheaths of the tendons and capsules of those joints which are provided with fibrous capsules, and the ligaments surrounding the other joints. To these may be added the membranes which have a mucous covering spread over them; such as the portions of the periosteum which line the palate, the nasal sinuses, and other internal cavities; and, finally, the capsule of particular organs, as the sclerotic coat and cornea of the eye, the tunica albuginea testis, and the capsules of the kidneys, ovaries, &c. All these parts, with the exception of the capsules of the solid organs, appear to be the frequent seat of rheumatic affections." The author then proceeds to notice that peculiar modification of rheumatism in which the nerves are principally attacked; and from analogy he is led to believe that, of the parts which belong to the nervous apparatus, the fibrous tunic, or neurilema, is the one most subject to the attacks of rheumatism. The fibroserous membranes, the pericardium and dura mater, are then brought under review, and the fibrous capsules of certain joints, especially the hip and shoulder; and then we come to the synovial membranes, comprising the subcutaneous bursæ, the synovial sheaths of tendons, and the synovial capsules of joints. "These are all of them subject to the attacks of rheumatism; and, when it occupies these structures, it may be recognised by the situation, the degree, the character, and the form of the swelling. The swelling is much greater in degree, and occurs much earlier after the commencement of the attack than that which is caused by an affection of fibrous structures. The character of the swelling is that of an elastic, circumscribed, fluctuating tumor; and its form is that of the distended synovial membrane, modified of course by the surrounding ligaments and tendons, according as these confine or admit of its free distension and protrusion. "Another point of difference between rheumatism of the synovial and that of the fibrous membranes, which may be here briefly alluded to, is that the fever and constitutional disturbance are much greater in proportion to the degree of local inflammation in the latter, than in the former case. "Again, it may be mentioned that, of internal organs, the heart and pericardium are chiefly prone to sympathise with an affection of fibrous structures; but the brain, and its meninges, with that of the synovial membranes." The author sums up by giving the following as the varieties of rheumatism founded on the peculiarities of anatomical structure: -1. Rheumatism of the fibrous membranes, including under it the three subdivisions of, 1, rheumatism of the tendons, fascia, ligaments, and muscles; 2, rheumatism of the periosteum; and, 3, rheumatism of the nerves or their fibrous sheaths.-2. The second great division of rheumatism includes the affections of synovial membranes. The second Lecture is devoted to a description of the general and diagnostic symptoms of these forms and modifications of rheumatism, and to an explanation of their separate appearances and occasional combinations. Previous to this, however, a few remarks are offered on the exciting and predisposing causes of rheumatism, and on its intimate nature or essence. Dr. Hawkins, after expressing his distrust of Sir GEORGE BAKER'S theory, that neither gout nor rheumatism are really inflammations, but "that they have their seat in the exquisitely fine and slender radicles of lymphatic vessels," briefly notices the distinction between common and rheumatic inflammation; and then proceeds to the predisposition to rheumatism. This part of his subject is discussed with extraordinary brevity. We are simply told, that, whereas all circumstances which encourage corpulence and plethora predispose to gout, those which induce debility appear to give a tendency to rheumatism. Cautiously as this doctrine is worded, we yet think it quite untenable. The occurrence of acute rheumatism in fat and plethoric persons is far from uncommon; and accidents productive of local weakness, such as strains and contusions, are just as often the forerunners of gout as of rheumatism,-perhaps even oftener. After giving us but one page on the predisposition to rheumatism, we were surprised by finding five pages devoted to the comparatively uninteresting subject of the Diagnosis of Acute and Chronic Rheumatism. Rheumatism of the Fibrous Structure, as distinguished from that of the synovial membranes, next comes under notice; and, as this is the main feature of the work, we must dwell a little on it. The author acknowledges to have imbibed this distinction from one of the physicians to St. George's Hospital. The publication of a series of Cases of Rheumatism in some late Numbers of this Journal, July and August, 1826, will at once suggest to our readers the name of Dr. CHAMBERS as the individual here referred to. These views of rheumatism, indeed, are familiar to all who have been in the habit of attending St. George's Hospital for some years past; and, as we are informed, they have been fully developed in the lectures now in the course of delivery by Dr. Chambers, in the Theatre of Great Windmill Street. Popular language, as Dr. Hawkins remarks, has long borne testimony to such a distinction, the term rheumatic gout being applied to the synovial species of the disorder; and we are disposed to agree with the author, that, at the commencement of a rheumatic attack, the discrimination of the affected structures may be made; not perhaps, as he states, invariably, but at least very frequently. It is a matter of doubt with us whether, beyond this, the distinction is of any real value. The quantum of practical benefit resulting from this nicety in pathology, may be estimated from the author's own statement: these affections differ from each other more in degree than in kind, we must hesitate ere we agree with the author's concluding observation, that, if the varieties of rheumatism are more attentively studied, a still closer adaptation of means to their cure may even yet be effected." Some useful observations occur at page 64, on the symptoms of periosteal and nervous rheumatism, which we regret that our limits will not permit us to transcribe. We pass on, therefore, to Lecture third, which treats of the Rheumatic Affections of the Heart, and other internal organs, with a slight allusion to Rheumatic Ophthalmia. The obscurity in the symptoms of pericarditis is first touched on, and two interest ing cases are related, wherein furious delirium was the leading symptom during life. The following remarks are too valuable to be passed over. "Some advantage of this kind has already been obtained in the choice of remedies for the treatment of rheumatism. It has been ascertained that colchicum is almost specifically adapted for the cure of the synovial species; but that it more frequently disappoints our expectation in fibrous rheumatism, the acute form of which yields most readily to calomel and opium in considerable doses, with the interposition of occasional purgatives, and followed up by moderate sudorifics; and, finally, by the administration of cinchona. Topical remedies, of the subjects of this affection as has been mentioned, are chiefly proper for articular rheumatism; but blisters have also a good effect in lumbago and sciatica, and deepseated pains of the joints. Sarsaparilla and alteratives are required for chronic and cachectic cases, particularly for affections of the periosteum." "From an examination of the cases which have been recorded of rheumatism of the heart, it appears that a large proportion were young persons under thirty years of age in most of them there were marks of constitutional or acquired debility many were of a slender and delicate form, and pale and languid in their appearance. In these circumstances we have a strong confirmation of the remark, that exWhen, however, we consider cessive bleeding in the treatment that the different kinds of rheum- of acute rheumatism, or any meaatism are frequently met with in sures calculated to induce debilicombination, or in close succes- ty, increase the danger of metassion to each other, that both tasis to the heart and pericardium; species are avowedly under the and that the exhibition of bark, influence of the same causes, as soon as it can be borne with predisposing and exciting, and safety, is of considerable efficacy that the respective remedies for in counteracting this tendency. -- |