or in the fibrous tissues themselves, or in both— and which, in fact, constitute the disease itself; and this feeling is in no degree diminished by the recollection that we have on some occasions, in the treatment of this disease, met with such success with one class of remedies as to lead us to believe that the difficulties we had heard described, and even ourselves seen in the treatment of rheumatism, were an exaggeration and a myth, and would in future disappear under the talismanic influence of the last new mode of treatment; and that we have, at another time, under apparently the same circumstances, found that the remedial measures which were previously adopted with so much success, have on subsequent trials proved so ineffectual as to compel us to admit that our knowledge of the true nature of this disease has hitherto been imperfect, and its treatment to a great extent uncertain and empirical.

The question which we first have to decide is, what is rheumatism? Dr. Watson, in his excellent work on the "Principles and Practice of Medicine," describes rheumatism as inflammation of the fibrous tissues, but yet that it is not inflammation of the common kind; "at any rate it does not reckon among its events, as common inflammation does, either suppuration or gangrene. If sup

puration sometimes occurs, and it certainly occurs very rarely, it is because the rheumatismal inflammation has extended to contiguous textures, and then has run the ordinary course of inflammation."

A little further on in the same lecture this eminent and able physician retracts, or at all events' modifies, this opinion in some degree, when he says, "In truth, acute rheumatism is a blood disease. The circulating blood carries with it a poisonous material, which, by virtue of some mutual or electric affinity, falls upon the fibrous tissues in particular, visiting or quitting them with a variableness that resembles caprice, but is ruled no doubt by definite laws, to us as yet unknown." Dr. Fuller, who is one of the most recent writers on this subject, believes with Dr. Todd, Dr. Prout, and others, that lactic acid, being retained in the blood instead of being eliminated by the skin, is the special materies morbi of the disease; that this materies morbi is generated within the system and not absorbed from without, and the development is called into play by any long-continued depressing influence upon the system. When the system is thus deranged, and rheumatic poison is present in it, any disturbing circumstances, even of temporary duration, such as over-fatigue, anxiety,

Dr. Fuller

grief, or anger, by rendering the system more susceptible of its influence, may prove the accidental or exciting cause of the disease, and exposure to cold or atmospheric vicissitudes is almost certain to induce an attack. thinks that although the fibrous and fibro-serous textures are those which chiefly suffer, still, from its being a blood disease, all parts of the body must be more or less liable to be affected.*

This view of the pathology of rheumatism is extremely ingenious and highly creditable to Dr. Fuller, but as my views on this subject are entirely at variance with his respecting lactic acid being the materies morbi of rheumatism, and as I dissent from Dr. Watson as to the existence of inflammation of fibrous tissues at all, I am unable to subscribe to the doctrines of either of these gentlemen. It is unnecessary to enter further upon the opinions of others; the controversy would be endless and the result useless. In no class of diseases is the old saying of tot homines tot sententiæ so applicable as in this; most men are content to say, never mind what it is can you tell us what will cure it?" A dozen different men would in all probability suggest as many different remedies. The want

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* From Braithwaite's "Retrospect of Medicine," vol. xxvii.

of unanimity as to the nature of the malady, and the discrepancy which exists as to the most efficacious mode of treatment, amongst men well informed on professional subjects, and with whom, on most points, no difference of opinion would exist, is the most conclusive proof that the complicated and eccentric nature of this malady has hitherto enabled it to evade the efforts which have been made to show with scientific precision and certainty its true nature, in order that its successful treatment may be based, not as at present, on empirical traditions and observations, but on those rational principles which enable us to predict a cure not as a precarious probability but as a moral certainty. This great discrepancy of opinion, both as regards the nature of the malady and the most appropriate treatment of it, is in a great measure due to its having been regarded at one time as too exclusively dependent on an inflammatory condition of the fibrous tissues; at another time, and by another set of pathologists, as too exclusively dependent on the presence of a materies morbi in the blood; whereas I believe the true solution of the complicated nature of this malady and of its eccentric and variable peculiarities is to be found in the fact that cold and moisture, the commonly recognised exciting

causes of the disease, give rise to the formation at one and the same time both of the morbific matter and that peculiarly enfeebled condition of the fibrous structures that renders them prone to become the nidus of that morbific matter, and it is to the presence of this morbific matter in the circulatory system that the high vascular excitement which characterizes the disease is due, while the local symptoms are attributable to the accumulation of the particles of this irritating matter in the dense unyielding structures which are the especial seats of the disease.

I believe the urate of soda to be the materies morbi of both gout and rheumatism, and that the difference in form and degree between the two diseases depends, partly on the difference in the chain of events which has preceded and led to the formation of the morbific matter, and which has, at the same time, exercised an important influence on the character of the vital fluid itself, and partly to the different effect which this animal irritant exercises on two opposite conditions of the blood. This opinion is in some degree confirmed by the fact that in synovial rheumatism, which is popularly, and I think properly designated rheumatic gout, the constitutional symptoms partake in a greater or less degree of the character of