whole night, and often longer, the attendant being afraid to remove the restraint, lest evil to himself or the patient should follow. This continued night after night -the patient generally keeping one position-the sustaining parts soon give way, and then follow those dreadful ulcerations, so frequently terminating in the sacrifice of life." (pp. 84 et seq.)

We have now abstracted some of the more interesting and important portions of Dr. Steward's notes. His remarks, though-for the extent which his work embraces-necessarily very brief on many subjects, uniformly exhibit him to be possessed of much experience and judgment in the management of the insane.

Dr. Steward concludes his work by alluding to the necessity of some change in the law of lunacy as it at present exists, by which the anomaly shall be removed, that, while the liberty of the individual may be restrained, there exists no means of legally managing his estate, except by issuing a commission of lunacy-a step which, from the expense attending it, and the objection on the part of the friends to the publicity it entails, is usually deferred till the lunatic becomes incurable, and when after his property has sustained great injury. As the remedy of this evil, Dr. Steward suggests the delegation of a power to the commissions to enter upon the private investigation of cases reported by the friends of the patients, and to appoint provisional trustees, whose office should expire when the patient shall be deemed sufficiently recovered to reenter upon the charge of his affairs, or at a time to be fixed beforehand, or when, being deemed incurable, no objection is felt to the ordinary mode of proceeding. We think the suggestion worthy of consideration.

ART. VI.

Traité des Maladies des Articulations; accompagné d'un Atlas. Par A. BONNET, Professeur de Clinique chirurgicale à l' Ecole de Médecine de Lyon, &c. Paris, 1845.

A Treatise on Diseases of the Joints. By A. BONNET, Professor of Clinical Surgery in the Medical School of Lyons, &c.-Paris, 1845. 2 vols. 8vo, pp. 1229.

In our January Number (Brit. and For. Med. Rev., vol. xxi, p. 124) we gave an outline of MM. Bonnet and Richet's views respecting the general pathology of diseases of the joints, and we shall now proceed to examine M. Bonnet's doctrines as to the general etiology and general treatment of those affections.

The causes of diseases of the joints may be internal or external, and the most important of the former, on which M. Bonnet especially dwells, are those general or constitutional dispositions termed diatheses. The existence and character of a diathesis can only be known by its effects-its intimate nature is entirely unknown; but if we see fungosities, pus, or tubercles deposited (especially if they are so in several organs simultaneously), without any appreciable external cause, we infer that there is a disposition to such deposition, and that disposition is a diathesis. M. Bonnet, as we have seen, divides the morbid products in diseases of the joints into

three classes: those which become perfectly organized-those whose organization is arrested-and those incapable of organization; and he chaterizes the diatheses that most commonly produce diseases of the joints according to their tendency to excite the deposition of one or other of those species of morbid products. The first is the rheumatic diathesis, the most favorable of all, in which there is a tendency to deposit plastic lymph; the second he terms the fungous diathesis, as it is characterized by the formation of "fungosities;" the purulent, the tubercular, and the gouty diathesis belong to the third class, being accompanied by the deposition of tubercle, pus, and uric acid, all incapable of organization. Often, however, there is no marked line of distinction between some of those diatheses. However distinctly marked in some cases, in others they may be mixed; fungosities, for example, are frequently infiltrated with pus, or may coexist with chronic abscess in some other situation. Indeed this liability to fusion has caused, M. Bonnet maintains, several really distinct constitutional conditions to be confounded under the common appellation of scrofula. Thus he considers the tubercular diathesis as different from scrofula; and this distinction made, he urges that among the other patients commonly termed scrofulous, individuals presenting very different general characters may be found. Some are pale, emaciated, with sallow cheeks, thin eyelids, lips, and septum nasi, and exhibit no trace of enlargement of the glands; these are the characters of the purulent diathesis, and they prevail in persons affected with chronic abscess. In others again the face is full, the eyelids, lips, and alæ nasi tumid, the glands of the neck usually large, and the complexion is commonly more or less florid, at least until the health has been undermined by the progress of disease. Such patients are usually liable to congestions with mucous secretions, their eyes are frequently red, the eyelashes adhering from a tenacious mucous secretion, slight causes excite obstinate catarrhs, and in children a crusted exudation often occupies the hairy scalp. Such are the signs of the scrofulous diathesis properly so called, which M. Bonnet prefers terming the "fungous" diathesis, as it is with this diathesis that "fungosities" most frequently coexist. (Vol. ii, pp. 25 et seq.) Still, as has been already said, those diatheses shade dually into each other and often coexist; and this circumstance shows a close relation between them, which, M. Bonnet argues, is confirmed by other considerations. Thus their causes are all more or less common; they are all hereditary, and such is their connexion that parents affected with one diathesis may transmit either of the other to their children; their most frequent occasional causes are also the same, viz. chills, damps, suppression of the cutaneous secretion, eruptive fevers, &c. Their general symptoms also agree in this, that the functions of calorification, of the digestive organs, and of the skin, are deranged in each; they also frequently demand the same treatment, e. g. stimulating the skin, sulphureous and saline spas, iodine, alkalies, tonics, &c. Such points of agreement indicate that however widely different in other respects, something essential is common to all. What is it, then, that so greatly modifies this common term? To this M. Bonnet replies:

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"I am inclined to believe that the same morbid principles introduced into the economy produce sometimes one, sometimes another, of these affections, solely because of the different predispositions which are peculiar to each individual and

to each age; children are predisposed to the secretion of pus and fungosities, they become scrofulous; youths and adults have a tendency to inflammations more rapid in their progress, they are predisposed to acute rheumatism; in middle and advanced life there is a tendency to maladies slow in their progress, and chronic rheumatism is of frequent occurrence. In my mind, scrofula and rheumatism have this in common, that they are caused by the same morbific principles, and their differences solely depend on the way in which each age and each constitution reacts under the influence of this cause." (Vol. i, p. 104.)

M. Bonnet founds his diagnosis, and consequently his prognosis, of chronic diseases of the joints mainly on the external characters indicating the existing diathesis. Thus, when fluctuation cannot be detected in a diseased joint, it is often impossible to determine by manual examination whether the fibrous or fungous tissue deposited in the joint is or is not infiltrated with pus; no doubt the more indurated the tumour the greater is the deposit of fibrous tissue and the more favorable the prognosis, while, on the contrary, the more yielding it is, the more do "fungosities" predominate; but in doubtful cases a tolerably accurate conclusion can only be arrived at by considering the general condition of the patient. Thus, if a chronic abscess coexists with a diseased joint of a doubtful character, we may certainly conclude that there is a tendency to the formation of a chronic abscess in the joint; while if fungosities exist elsewhere they are present in the joint also. But, above all, the general condition of the patient must be scrupulously examined the countenance, complexion, &c., the capability of resisting fatigue and vicissitudes of temperature. If the signs of the purulent diathesis predominate, though "fungosities" only are deposited, they will probably become infiltrated with pus, while, if the scrofulous diathesis is well marked, fungosities, however soft, may escape suppuration, and become converted into fibrous tissue; and, finally, when the general signs of a good constitution are present a favorable issue may be anticipated, as organized matter has most probably been secreted. The same considerations are our only guide when there is no appreciable lesion of a joint in which the patient experiences some pain and some restraint of motion; in such a case it is only possible to say what will be the tendency of the disease should it become aggravated. If the chronic purulent diathesis exists those pains forebode a chronic abscess. If the scrofulous diathesis prevails fungosities are imminent. We have set forth M. Bonnet's views in this matter pretty fully, inasmuch as the following brief quotation shows the cardinal importance he attaches to them:

"If this work differs from those already published on diagnosis, it does so particularly in the care taken to estimate concomitant lesions and the general state of the constitution." (vol. i, p. 113.)

The two great external causes of diseases of the joints are cold, and especially damp. Their influence indeed is generally admitted; but M. Bonnet complains that the special conditions which render them innocent or injurious have not been determined, and this point he investigates at great length. As regards cold, M. Bonnet's doctrine is just this-1st, that the chill produced by cold air is much more injurious than that caused by cold water; and, 2d, that though the action of cold, especially cold air, is very dangerous when perspiration has been excited by bodily exertion, it is almost innocuous, and if the refrigerating medium is cold water completely

innocuous, when passive perspiration exists, such, for example, as is produced by enveloping the body in flannel or other bad conductor of heat. This opinion M. Bonnet chiefly founds on the results of the hydropathic treatment, which he asserts has never been followed by inflammatory mischief in any case, including some hundreds in his own practice. Damp, however, is the most frequent agent that leads to diseases of the joints, and its influence is the more mischievous, as it acts by deteriorating the constitution. The vapour of pure water, or simple atmospheric moisture, is indeed, M. Bonnet thinks, quite harmless, but the moisture exhaled from walls recently built, frequently wet, or otherwise rendered damp, or derived from any similar source, is eminently injurious; producing in early life the fungous or purulent diathesis, or both, and generating rheumatism in adults. It is true that many under such circumstances apparently escape with impunity, but M. Bonnet maintains that their health is nevertheless almost uniformly really impaired. Thus the parents of a scrofulous child will often deny that the dampness of their dwelling has caused the disease, alleging that their own health is unimpaired though they inhabit the same house; but M. Bonnet has almost invariably found that their health is impaired, they are liable to catarrh, sore throat, ophthalmia, wandering pains, &c., on exposure to those transitions of temperature which are inseparable from the ordinary occupations of life. In support of these statements M. Bonnet enters into several details respecting the construction of the houses, and the habits of the manufacturing population in Lyons and the adjacent districts, to which we can only thus generally refer. (Vol. i, pp. 92 et seq.) In the chapter on general therapeutics, M. Bonnet first discusses the local and then the general treatment; but we shall consider the latter subject first, as the chief indeed the only point therein requiring notice is directly connected with M. Bonnet's etiological views.

In constitutional diseases of the joints, according to M. Bonnet, the functions that are most frequently deranged are those of the skin. In many scrofulous and rheumatic patients those functions appear to be natural; but they are really disordered unless the perspiration is acidpossesses its peculiar smell-contains its normal salts-and unless the individual, when suitably clothed, sustains no sensation of cold in ordinary alterations of temperature. But all those conditions seldom exist in constitutional diseases of the joints, and, where they do not, our primary object should be to restore them; in effecting which, according to M. Bonnet, hydropathic baths are the remedy to which there is nil simile nil secundum.

We of course shall not describe the mode of administering those baths, as any of our readers who may not be acquainted with the process will find a full account of it in a former Number of this Journal. (No. XXVIII, p. 429.) But we shall briefly state the circumstances which M. Bonnet says specially indicate and contraindicate the practice, with the precautions he recommends in adopting it.

The hydropathic baths, then, are always indicated-when the perspiration is suppressed on the one hand, or is passive and copious on the other, and also when it has lost its odour-when the cutaneous circulation is languid when the extremities are habitually cold, or when a sensation of coldness is experienced in or near the affected joint-when damp has

XLIII-XXII.

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been the exciting cause of the disease-when the pain, stiffness, &c., of the joint increase in winter and autumn, and diminish in summer, or generally are influenced by changes of weather-and, finally, when the patient is subject to wandering pains or transient shiverings. (Vol. i, pp. 167 and 553.) On the other hand, the treatment is contraindicated when the thorax, to use M. Bonnet's phrase, is impressionable, when there is habitual cough, and a fortiori when pulmonary tubercles exist; there is little hope of success when the patient is pale and much enfeebled, the favorable effects of the baths being the more decided the stronger and the greater the power of secretion of the individual. At first, if the patient is feeble the bath should be at the temperature of 18 or 20° C. (64 to 70° F.) and gradually lowered to 15°, 120, and 10° C. (59, 53, 50° F.), and ultimately, when opportunity offers in winter, gradually lowered to 0° C. (32° F.) The time of immersion in the bath should be similarly graduated from two minutes to five or even ten minutes, which latter period should seldom be exceeded; but, irrespective of time, whenever the shock is severe, the patient shivering and his teeth chattering, he should be at once removed from the bath, as otherwise the action may be imperfect, or even entirely fail. M. Bonnet confirms the statements of others, that the perspiration during the first stage of the process has very frequently an odour sui generis, and, in scrofula especially, is often unsupportably fetid. Under the influence of the treatment the skin becomes soft and perspirable, the fetid perspiration, the coldness of the extremities, the sensitiveness to alternations of temperature, disappear, and the skin becomes more vascular, and assumes a healthy colour. From all this M. Bonnet thinks that there is no hypothesis involved in the conclusion that the hydropathic treatment acts by eliminating morbid principles, re-establishing natural perspiration, and invigorating the function of calorification. He is also quite satisfied that the injurious consequences popularly attributed to chills never follow the use of hydropathic baths, and accounts for this by the distinction he seeks to establish in his chapter on etiology between perspiration excited by exercise and that caused by warm clothing, and also between the chill produced by cold air and by cold water. We have already stated the general indications specified by M. Bonnet for the employment of hydropathic baths :-now for a few words respecting their applicability in particular diseases. M. Bonnet disapproves of them in acute inflammation, whether rheumatic or not; but he was induced to try the wet sheet in a few such cases, and without a favorable result. When, however, the malady is protracted, say beyond two months, and tends to become chronic, the fever having subsided, but swelling pain, stiffness, &c., remaining, then he has found the hydropathic treatment most efficacious. (Vol. i, pp. 369-73.) In the chapters on chronic arthritis and chronic rheumatism several cases thus treated are detailed. One is a case of chronic rheumatism of ten years' duration; there was hydarthrosis, with thickening of the soft parts of both knees and one wrist, displacement of the lower extremity of the ulna, nodosity of the joints of several fingers, and a similar condition of the joints of the tarsus. The patient suffered great pain, especially at night, and was unable to walk, the state of the hands preventing the use of crutches. The disease, moreover, had been contracted in the rainy season in the West Indies. After the administration