WHITE-SWELLING. 



Rheumatic wliite-fwellings being invariably accompanied, 

 at their commencement, with an inflammatory character, 

 there can be no doubt, that, at this period of the complaint, 

 the great indication is to take fnch meafures as are beft cal- 

 culated to leflen and fiibdue infldmniation ; and bleeding is 

 what fhould firft be praftiM. When the patient is ftrong, 

 robuil, and much fever exifts, he may be bled once or 

 twice in the arm ; but, in other cafes, we are to be content 

 with drawing blood from the part afftfted with leeches, or 

 by Clipping. If leeches be ufed, they (hould be applied to 

 both fides of the joint, and eight or ten ounces of blood 

 ought to be thus taken away. The application of thefe 

 animals (hould alfo be repeated at proper intervals, more or 

 lefs frequently, according to the violence of the fymptoms, 

 and the ftrength of the patient. In cafes of this defcrip- 

 tion, drawing blood from the difeafed part itfelf is found to 

 be much more efficacious than general blood-letting, which 

 weakens the patient without proportionately leflening the 

 fwelling of the joint. 



Blilters are another means, as efficacious as topical bleed- 

 ing. Boyer recommends beginning with the application of 

 a fmall one to the front of the joint, where the leeches have 

 not been put ; and he fays, that it (hould be kept open, 

 until the bites of the leeches are healed on one fide of the 

 articulation, where a fecond bliller is then to be applied. 

 As foon as this is nearly healed, we are next advifed to lay 

 a third bliiler on the oppofite fide of the joint. By thus 

 continually changing the fituation of the bliller from one 

 fide of the articulation to another, a permanent counter-irri- 

 tation is kept up, which, fays Boyer, in all deeply-feated 

 inflammations, efpecially thofe which proceed from rheuma- 

 tifm, is much more efFeftual, than carefully maintaining a 

 difcharge from a fingle bliller. 



In conjunftion with the foregoing means, the limb (hould 

 be kept moderately and uniformly warm by covering it with 

 flannel ; a low diet is to be obferved, cooling beverages 

 prcfcribed, and the aftion of the bowels regulated by 

 clyfters. Thus, the feverity of the pain may generally be 

 lelTened, and the inflammation diminiihed. If the pain, 

 however, (hould ftill continue to be violent, Boyer recom- 

 mends the ufe of topical anodyne and narcotic applications. 

 He Hates, that, in this circumftance, he has often employed 

 with fuccefs opiate and camphorated liniments ; fomenta- 

 tions compofed of a folution of the extra£l of opium in 

 water ; a llrong decoftion of poppies, &c. He thinks, 

 however, that fuch applications (hould never be ufed, unlefs 

 the pain be very fevere. 



When the inflammatory (lage is over, topical refolvent 

 remedies are to be employed, and their e(Feft is to be pro- 

 moted by exhibiting mild opening medicines at fuitable in- 

 tervals. The moll eflTeftual refolvent applications, and 

 thofe which are moll commonly tried in thele cafes, are, dry 

 fridtions with a piece of flannel, impregnated with the 

 vapour of benzoin, liniments containing ammonia and 

 camphor, amraoniacal plallers, foap-liniment, lotions of 

 vinegar, fpirit of wine, and the muriate of ammonia, &c. 

 Mr. B. Bell had a very high opinion of the good effefts of 

 rubbing the joint with camphorated mercurial ointment ; 

 but Boyer aifirms, that he has often tried the laft applica- 

 tion, and that his experience leads him to impute whatever 

 benefit arifes from its employment, chiefly to the fridlions, 

 which redden and promote the circulation in the fliin. 



By a perfeverance in the judicious ufe of the means 

 above fpecified, rheumatic white-fwellings may fometimes 

 be cured ; but it often happens, that, after the pain and 

 fwelling have fobfided, the joint remains quite ftiff and 



motionlefs, and every attempt to move it caufes confider- 

 able (uffering. In the majority of cafes, fuch llifFnefs de- 

 pends almoll entirely upon the retraaion of the mufcles, 

 tendons, and ligaments, and lemands the fame treatment as 

 a falfe ancl'.ylofis. Si-e Anchylosis. 



When the difeafe refills the foregoing treatment, and is 

 of long fl;andiiig, the cure is more difficult, inafmuch as the 

 thickening of the ligaments, and the effufion of a fero-albu- 

 minous fluid into the cellular fubftance around them, are 

 more confiderable, and the bones and cartilages are likewife 

 at the fame time affefted. In this circumflance, if there be 

 any hope of cure, the furgeon mull have recourfe to more 

 powerful means, which we fliall mention in fpeaking of the 

 treatment of other defcriptions of white-fwel.ing. 



In white-fwellings, arifing from an external caufe, fuch 

 as blows, falls, &c. we mufl; firll lelTen the inflammation by- 

 general and local bleeding, low diet, cooling aperient beve- 

 rages, fomentations, and emollient anodyne poultices. Af- 

 terwards, when the pain and tenfion have fubfided, refolvent 

 appHcations are to be ufed, and the patient is not to be 

 allowed to move the limb, as long as there is any danger of 

 a renewal of the pain and irritation by exercife. 



Scrofulous white-fwellings in an early llage prefent 

 dilFerent indications, according to the circumllances with 

 which they are accompanied. A fall, or blow upon a 

 joint, being fometimes the exciting caufe of thefe tumours, 

 any accident of this kind m a perfon evidently difpofed to 

 fcrofula demands the utmod attention and care. No 

 means (hould be negledled which are at all likely to leffen 

 the pain and irritation in the aflFefted joint, and in particular 

 the bmb ought to be kept perfeftly quiet for a long time. 

 Scrofulous white-fwellings frequently come on, as it were, 

 fpontaneoully, without the concurrence of any external 

 accident, and their attack is attended with a dull, fometimes 

 an acute pain in the very cavity of the joint, which at fird is 

 not affedled with any manifell degree of fwelling. In this 

 circumllaiice, the furgeon mull endeavour to prevent the 

 progrefs of the difeafe by enjoining the patient to refrain 

 from moving the joint, and by direfting the employment of 

 foothing local applications, which are afterwards to be fuc- 

 ceeded by blillers, or an iflue. 



In the cafes of white-fwelling, which appear from Mr. 

 Brodie's account to depend principally upon inflammation 

 of the fynovial membrane, tlie acute (lage of the difeafe is 

 to be treated by general and local bleeding, aperient medi- 

 cines, cold topical applications, or fomentations, and emol- 

 lient poultices. When the aifeftion has become chronic, 

 this gentleman recommends perfect red, and leeches, or 

 cupping, followed by the application of a large blifter. 

 Under this treatment, he fays, " the pain is relieved, and, 

 in a few days, the fwelling, as far as it depends upon the 

 fluid c»llefted in the cavity of the joint, is much diminiflied. 

 Even where the tumour is folid, arifing from the elfufion of 

 coagulating lymph, it will in a great meafure fubfide, and 

 fometimes be entirely difperfed, provided the lymph has 

 not yet become organized. A fingle bliller often produces 

 marked good eflfefts ; but, it is generally necelFary to repeat 

 both the blifter and the blood-letting feveral times." 

 Mr. Brodie confiders the repeated application of bliilers 

 more efficacious, tlian a fingle bliller kept open witii the 

 avine cerate. When the inflammation has been much fub- 

 dued, he thinks moderate exercife of the joint rather bene- 

 ficial, and commends the ufe of a llimulating liniment, com- 

 pofed of Jifs of olive oil, and ^fs of fiilphuric acid. This 

 application, when too irritating, is to be weakened by an 

 additional quantity of oil, and it is not to be ufed before in- 

 flammation 



