CHRONIC ARTICULAR RHEUMATISM. 537 



of the patient. This form also of chronic articular rheumatism is very 

 obstinate, and, once rooted, often lasts for life. It is frequently com- 

 plicated with muscular rheumatism, and not unfrequently with those 

 forms of neuralgia and paralysis which are usually termed rheumatic. 

 TREATMENT. The form of chronic articular rheumatism, limited to 

 certain joints, requires chiefly a local treatment ; while vague chronic 

 articular rheumatism, on the other hand, requires to be treated gen- 

 erally. In recent cases, the best local treatment is by leeches or wet 

 cups. To attain satisfactory results, these should be frequently re- 

 peated at moderate intervals ; they then do excellent service, and 

 cannot be replaced by any other remedy. Even in obstinate cases it 

 is well to begin the treatment with leeches or wet cups, unless con- 

 traindicated by the general state of the patient. The result of the 

 first abstraction of blood must decide us whether to repeat it in such 

 cases also, or to use derivatives instead. Among the latter, such as 

 redden the skin, or cause superficial inflammation of it, are to be pre- 

 ferred to those which, from their volatility, irritate the nasal mucous 

 membrane, but cause no perceptible change in the skin. Heretical as 

 it may sound, we still believe, that when the disagreeable opodeldoc, 

 volatile liniment, spirits of camphor, as well as the fragrant mixtura 

 oleoso-balsamica, prove beneficial, their efficacy is chiefly due to the 

 manipulation of the parts. For support of this assertion, we may re- 

 fer to the fact that of late even the laity, who formerly used the above 

 remedies as a matter of course in all rheumatic affections, use them 

 less frequently, and employ frictions with French brandy and salt in- 

 stead. The application of sinapisms and frictions with spirits of mus- 

 tard, by which the skin is temporarily reddened, are sometimes of un- 

 doubted benefit, and, when continued regularly, may cause permanent 

 improvement. Frictions with veratrine and chloroform liniment induce 

 peculiar sensations in the skin, which, to some extent, speak for their 

 derivative action. In mild cases I have employed a solution of veratria 

 (gr. vj x), in chloroform ( f ss), and mixt. oleoso-balsamica ( ij), 

 with apparently favorable effect. Vesicants are far more efficacious 

 than rubefacients ; among these may be classed painting the skin 

 with tincture of iodine, as it causes the epidermis to be thrown off; 

 and, if the undiluted tincture be used, it often induces blisters. In 

 very obstinate cases, in order to secure a good result, the portions of 

 surface denuded of cuticle must be kept suppurating for a time. I 

 consider a powerful douche over the affected joint as the most efficient 

 derivative, and even place it before the hot iron and moxae, which art 

 also advised in localized articular rheumatism. We may readily sat- 

 isfy ourselves that an energetic douche will leave a hyperaamia of the 

 skin lasting for several hours I have no personal experience of the 



