nurses; and since, among a large portion of the community, the treatment of infantile diseases will necessarily continue in the hands of the uninformed, it would probably be more advisable to treat the subject rationally, in a language which the indocti and the anicula, both in and out of the profession, would be able to comprehend. To what particular class of readers the author addresses his treatise we know not; for while the unlearned are denied any participation of its contents, the learned members of the profession, we apprehend, must be already in possession of the knowledge which it contains; and on the more important topics it will appear to them to be deficient. It may be characterised in the author's own words, "opusculum minutum sane et exile, in quo nihil fere quod non dictum ab aliis, plurima etiam trita invenies." In the early chapters we find a larger portion of good sense than of useful information. The 2d, 3d, and 4th, containing merely an enumeration of the most common emetics, purgatives, and astringents, with their doses; and the 5th, which describes the symptoms of general indisposition, might, perhaps, have been omitted without detriment to the reader, not only because every tyro in medicine must be familiar with the whole, but because in subsequent chapters the author is led to repetition. Chapter 13, de inflatione, might be translated to the anicula with advantage. "Mulieres, quibus alendi infantes committuntur, multa quidem loquuntur de inAatione. Ad hanc unam vagitum, singultum, vigiliamque, vomitumque pariter referunt. Hoc tamen impune; nisi mos quoque esset ad affectum pene anilem medicamenta periculo plena adhibere. Quippe qui aqua mentha piperitidis, aut spiritu vini meraciore hanc student depellere, verendum est ne ægrum, quam morbum, prius extinguant. Ante omuia igitur videndum est, ne plus assumat æger, quam concoquat; sed potius exiguum cibum sæpius in die, quam uno tempore pleniorem. Tum quoque cibi genus facile esse oportet, aut quædam in eo mutari. Præter hæc, sæpe conveniunt pulveris alieujus amari et aromatici grana pauca semel aut bis quotidie sumpta, et simul rhabarbari quantum ventrem emolliat." With respect to the more serious and important diseases, both the history of the symptoms and the methods of cure are in general related too briefly to be instructive, and the remedies are enumerated with too little discrimination as to the period, or type of the disease, to which they are particularly adapted, or in which they may prove injurious. The symptoms of the acute hydrocephalus are thus related. "Illius speciei, quæ serius nascitur, hæc signa sunt; febricula, dolores capitis repen tii, nausea, hebetudo, impatientia lucis, delirium, dilatatio pupillarum, genarum rubor, et modo veternus, modo distentiones membrorum, denique intra mensem mors." One remarkable symptom, strabismus, is omitted; and the impatientia lucis, and dilatatio pupillarum seem to be mentioned as compatible symptoms, although the former is obviously the result of an extreme sensibility of the retina, the latter of the opposite state of insensibility in that or gan: the one originating in an inflammatory state of the brain, and peculiar to the commencement of the disease, the other supervening in the latter stages, in consequence of effusion. That most im portant view of the disease, suggested by Drs. Quin, Whytt, &c. and grounded upon these opposite symptoms, and upon the extraordinary variations of the pulse, is entirely overlooked; and, of course, that remedy from which alone, perhaps, any hopes of success are to be derived, and which we believe we have seen effec tual in the onset of the disease, viz.topical bleeding, is not alluded to. In the chapter which treats of scarlatina, (a term which the author discards, prebably as unclassical, and substitutes the words febris rubra) the remedies are stated somewhat indiscriminately. "Hic morbus et angina, si unus idem qur non sint, eandem saltem curationem post lant. Itaque adversus hunc quoque utendu est decocto cinchonæ, et aromatibus, et et emplastris cantharidis; conservanday vires omnibus modis." Although the identity of the contagic which produces scarlatina and cynand maligna, has, we apprehend, been f established, yet the inference to t identity of the remedies required, is be no means admissible, nor can it be co sidered as sanctioned by general exper ence. No one affirms that the mild an confluent small-pox require the same re medies, although the identity of the origin be unquestionable; and we c ceive that the exhibition of wine cordials in the incipient stage of simp scarlatina would be a reprehensible pra tice, when the morbid heat is greates perhaps, than it is ever observed in an other febrile disease, and more especially since the evidence of the most experienced practitioners in this disease, confirms the advantage derived from gentle emetics and diaphoretics, and some even recommend the external use of cold water in its primary stage. If the active febrile actions be moderated in the commencement by these means, the subsequent prostration of strength is greatly lessened, and the necessity of recurring to bark and cordials greatly diminished. The tendency of the disease to debility in many constitutions, and especially in some seasons of its epidemic prevalence, will of course be kept in view by the discriminating practitioner, and will regulate the early or later exhibition of these stimulating remedies. Blisters, even in the cynanche maligna, are by many practitioners considered as of doubtful utility; but in scarlatina, unless there be also an affection of the throat, we know not to what good purpose they can contribute. Dr. Heberden here makes one mportant observation. « Gravis imprimis quæstio est, quam cito This question has been little considered till lately; and a series of observations will be necessary to decide it. It must be remembered that the disease has appeared to be communicated in several instances even later than the tenth day. (See Dr. Blackburn's Treatise.) In several of the chapters, as in the 30th, de morbis oculorum, and the 41st, de morbillis, &c. we find a perspicuous compendium of what is most commonly known in regard to those diseases. But on the whole, whatever addition this little treatise may afford to the wellmerited reputation of the author will be on the score of his knowledge and taste in classical literature, rather than on account of any improvement which he may have attempted to introduce into the practice of medicine in the diseases of children. ART. VIII. A Dissertation on Gout; exhibiting a new View of the Origin, Nature, Cause, Cure, and Prevention of that afflicting Disease; illustrated and confirmed by a Variety of original and communicated Cases. By ROBERT KINGLAKE, M. D. Member of the Royal Medical Society of Edinburgh, of the Physical Society of Gottingen, &c. 56. and Physician at Taunton. 8vo. pp. 318. affections we THE existence of gouty ind recognised in the most ancient reords of medical science. It appears hat an idea was early formed that the ttacks of this complaint are the operaion of a salutary effort of the constitution o throw off some greater impending vil, and that consequently, though it night be necessary in some instances to noderate its severity, it was seldom, if ver, safe to attempt to remove it altoether from the system. This opinion as been transmitted, almost without inerruption, to the present age, when Dr. Darwin and Dr. Heberden ventured to all in question the stability of the priniples on which it was founded. The athor of the treatise before us adopts is idea in its fullest extent, and in the llowing work undertakes to prove "That gout differs in no essential circumance from common inflammation; that it not a constitutional, but merely a local Ection; that its genuine seat is exclusively the ligamentous and tendinous structure; at its attack is never salutary; that it should ther be encouraged nor protracted; and constituted by transient excitement, without the more stationed features of inflamination. This is transient irritation only, and wants the essential and more durable circumstances of definite gout.” It would appear from these remarks that the Doctor confines his ideas of gout to the local affection of the limb, a surmise which we find confirmed as we advance in the work. It is, indeed, expressly stated that true gout "has its station exclusively in the ligamentous and tendinous structure." If, however, the author unusually restricts the meaning of the word, by confining it to the local disease of the extremities alone, we find that he deviates as widely from popular custom in the opposite direction, in conceiving that all inflammatory action of these parts is essentially the same, and that of course gout and rheumatism differ only in degree; he even goes so far as to consider the inflammation produced by external violence, as constituting the same kind of affection. Our readers will be doubtless anxious to learn the reasons which have induced Dr. Kinglake to form opinions so remote from those generally received. As far as we are able to comprehend his argument, it appears to be briefly this, he defines gout to be a simple inflammation of a ligament or tendon; hence it follows, first, that no part can be affected with gout that is not furnished with a ligamentous or tendinous structure; and, secondly, that every inflammation of a ligament or tendon must be gout. He, indeed, remarks, as a confirmation of his opinion, that it is often found extremely difficult to distinguish between gout and heumatism. "Experience bears ample testimony to the extreme difficulty of applying the prevailing ground of distinction between gout and rheumatism. Medical practitioners are often inextricably perplexed with the diagnostic phantom of gout and rheumatism. In consultation it becomes a subject of awful discussion. The irascible and bigotted are apt to dissent violently, sometimes indeed opprobriously; the demure, more gravely; whilst the polite conformist compromises the difficulty by denominating it rheumatic gout. Such puerilities surely are unworthy of medical science, and should not be tolerated in a philosophical age." But ought this to be considered as a proof of the identity of the two diseases, or of the imperfection of science, and the ignorance of physicians? Is this the only instance in which it has been found difficult to form a diagnostic between two diseases, the phenomena of which are sometimes seen to run into each other by almost imperceptible gradations, though their extreme cases are marked by sufficiently discriminating symptoms? Our present limits will not permit a full discussion of the question, a circumstance which we the less regret, as we feel confident that the majority of our readers will agree with us in thinking that the ordinary cases of gout and rheumatisma are easily distinguished from each other, both in their cause, appearance, and consequences. We think the author more successful in his attempt to controvert the popular idea that a quantity of morbific matter is formed in the constitution, that its deposition upon one of the extremities pro duces the gouty inflammation, and this disencumbers the system of the load by which it had previously been oppressed. This hypothesis, which had its origin in the doctrines of the humoral pathology, seems indeed to have derived little sup port from fact, and like the other parts of that once celebrated system, must now give place to the more correct ded tions of modern science. We cannot, however, adopt Dr. Kinglake's opini in their full extent, and consider that thr inflammation of gout presents nothing of a specific nature, and that it is cor nected only accidentally with a gener derangement of the system. With pretending to explain the nature of the connexion, we do not hesitate to assert that this connexion does exist in go and that it forms a decided and ve marked characteristic of the disease. Tre fallacy of the argument by which us author attempts to combat this opini we conceive our readers will not find difficult to detect. «Constitutional gout would pre-supp constitutional fabric of ligament and tendo in a state of inflammatory action from exte sive excitement. The physical conditions. requisite structure, therefore, to give effe what is strictly understood by gouty infia mation, can only be found in the jou What is erroneously termed gout in the st tem, is no more than distempered excitabil whether occurring originally or sympted atically, which may be concentrated arc termined on the articular fabric, where it be considered as an aggravation of the dista by increasing the previous degree of pun irritation, and in no instance to be remed But though he conceives that gout properly so called, is never a constitutional affection, he is obliged to acknowledge that a general disease of the system frequently accompanies the inflammation of the limb. "The general symptoms," says our author, arising from gouty inflammation are those of systematic commotions from sympa thetic influence. Much diversity is liable to occur in these general effects on the economy, according to the prevailing motive and conditions of the system, whether temperamental, habitual, or morbid. When equal energy pervades the frame, with entire freedom from visceral ailment, the diseased agitation will be equally distributed, and not disproportionately arrested on any particular organ, which will afford a general exemption from danger: on the contrary, if stomachic, hepatic, pneu matic, or any other organic affection should exist, the sympathetic effect of the gouty irritation may become preponderant on either of those parts, and induce a higher and more painful degree of visceral disease than would arise from its equal operation." As far as we can collect the author's meaning, it seems that he considers the constitutional complaints as not essential to the disease, and as only of secondary mportance. Indeed, we are afterwards nore expressly told that "visceral paricipation in gouty excitement loses its deal terror," when we come to consider hat "As the structure necessary to its confitution does not exist in the fabric of parts nore immediately invested with the function of life." and tendons. The continued irritation from this structural derangement will vitiate the vascular action of the periosteal covering of the gouty joitit, and force its exhalent vessels to bring back from the bony fabric more or less of ossific principles, with its diluent fluid. These principles are phosphoric acid and lime, which are combined with other substances into the form of organic bone, by the nutritive or generative vessels of that structure. haled on the gouty joint, aggregate and form in the temperature of the part the calcareous concretions, which, advancing to the cuticular surface by arterial impulse behind, and ulcerative decomposition before, at length appear through the skin in knots, or tophous tumours, and are finally discharged under the "The osseous but unossified substances ex name of chalk-stones." view of the phenomenon of the disease, After having taken a more minute he directly affirms "That no difference whatever exists between gouty and other forms of inflammation, but in circumstances of degree and situation." This position he endeavours to strengthen of inflammatory action. by taking into consideration the nature "Inflammatory excitement is universally similar, whatever be its degree or situation. The variety of remote causes by which it is induced, generates no correspondent difference in its quality. It consists exclusively of active violence. It is a sort of combustive state of vital motion, and may be aptly likened to fire, which, with whatever fuel kindled, burns with identical heat." He concludes the section by a review of the commonly received varieties in which gout makes its appearance. The distinctions usually adopted, tonic, atonic, retrocedent, and misplaced, he conceives to be more fanciful than real. They arise from different states of sympathetic energy, and visceral susceptibility for associative or sympathetic impression." He admits the existence of only two forms of the disease, which he thinks may be "descriptively expressed by the terms acute and chronic." These appear to correspond to the two first species, tonic and atonic; the retrocedent he endea vours to explain agreeable to his peculiar hypothesis, though in a way which we do not perfectly understand. With respect to the last, he does not hesitate to declare that ་་ Exquisite pain, shining tumefaction, ar ticular immobility, and systematic irritation, correctly exhibit the gouty malady: but the sanctioned doctrines of medical schools, as well as popular prejudice, would consider an attempt to assimilate the effects of a sprained joint with the gout, as but little short of sacrilegious innovation; as trifling with the holy mystery of inscrutable disease, and ren dering great things little indeed. Such declamation may be sounding, but it is nonsensical, without either point or authority, without any just regard for true science and its liberal investigation." Admitting the justness of the views brought forward in the preceding section, we are prepared for the following proposition. Rejecting the prevailing opinion of its being a disease of a specific nature, producible only by its peculiar cause, its contemplation is placed on the broad basis of simple inflammatory affection, acknowledg ing for its cause every stimulant agency capable of inducing that degree of excitement." External violence must, according to this opinion, be a prime cause of gouty inflammation; but in consequence of the peculiar minuteness and delicacy of the vascular system of the ligaments, whatever produces general indisposition of the body at large, is supposed capable of affecting these parts with inflammation. This general indisposition is, however, not itself any part of the specific disease of gout; on the contrary we are expressly assured that, in this case, the gout "owes its existence to accidental influence.” The author considering gout as a mere topical affection, we were almost surprised to find that he admitted it to be hereditary. may "However gouty inflammation have been repeatedly produced, whether by external violence, the gradual forma tion of altered structure, or local excess of distempered excitability on the ligamentous, tendinous, and fascial parts, the morbid changes induced will at length become so radically influential in the motive powers of the system, as to generate a transmitable state of temperamental susceptibility for mor bid affection." Dr. Kinglake, however, takes care to inform us that in these cases it is the gouty excitability” only which can be said to be hereditary. 66 We have before noticed that our au thor adopts the idea that gout and then matism are identical; we have, accordingly, variation of temperature enumerated as one of the most frequent causes of gout. The fifth cause of gout is "plenitude arising from dietetic excess and deficient exercise." It does not, however, appear that he conceives there is any specific connection between a disordered state of the stomach, and the gouty inflammation of the limbs. Agr. neral distention of the vessels is produced, the effect of which is experienced in different parts of the system; the fre quency of the gouty affection only marks the peculiar liability of the ligaments to participate "in the diseased irritation, induced either by undue distention er sympathetic influence." It is also ad mitted that the stomach may sympathire with an inflamed limb, but still the sto mach, in this case, has not the gout. F why? because, reader, there are no lig ments or tendons in the stomach, whica as you have already been informed, are the only seat of gout. Other remote causes successively fall under our review: excess in drinking, diminished se cretions, indigestion, occasional derange ment of health; and the circumstance of the gout having previously existed, re ders its return more to be apprehers & The author continues to adhere stead to his opinion, that the gout can subs only in a ligament or tendon, and that any connection which it may appear : have with the stomach, or constitution large, is merely accidental. We now proceed to the proxims:: cause of gout, a subject which has forded scope for much medical acutene and on which the present writer see to have expended all the force of genius. "The proximate cause of all gout resu from the aggregate efficiency of the remar causes, and is truly the disease itself. Is efficiency, or proximate cause, by which disease is constituted, consists in an agita. and an increased degree of vital or repais motion in the affected parts. |