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brane is principally affected in rheumatism. I have seen effusions of this kind occur as the first symptom of the disease; and I have an instance of it in a gentleman who is presently under my care. In this case, a circumscribed tumour, without the least previous pain, appeared in the course of the tendon of the ring finger of the left hand. Unable to explain the cause, the gentleman took little or no notice of it for some days, when it became the centre of pains which shot alternately to his wrist and to the points of his fingers, with frequent and most painful catchings of the tendon on which the tumour was situated. These pains and spasms occurred chiefly in the morning when warm in bed; and in a short time, the patient became unable to grasp any thing with his hand with any degree of firmness. When he applied to me, I desired him to grasp his left hand firmly with his right, pressing the thumb of the latter upon the aponeurosis palmaris of the former, and, in that situation, to try what command he had over his fingers. He could icstantly use them with the utmost ease and with the greatest vigour. I nest directed him to lay firm hold of the wrist of the affected hand with the other, and in this way to try the effect a bandage would produce. This gave him a more complete command still of the whole hand, and enabled him to do with it what he pleased. A clearer proof that the annular ligament was deficient in power, cannot be adduced. I endeavoured to persuade this gentleman to wear a bandage about his wrist, till a radical cure was obtained; but, highly amused with the success of the above experiments, and believing that he has the means of relief at command, he satisfies himself with the use of the fleshbrush, and, as occasion requires, with the repetition of these experiments, which never fail of the desired effect. Now, if we reflect that parts of similar structure, though far distant, are often observed to sympathize, we cannot wonder that the tendincus aponeurosis of the muscles, and all its processes, which are of the same nature and structure with the sheaths of the tendons, and indeed but a continuation of the same substance, should be simultaneously affected with them.
In the fourth place, from the fact that the same cause affects different parts of similar structure in different individuals, and in the same individual, perhaps, at different times, we might
judge, a priori almost, that it is not the muscular fibre, but the cellular membrane that is peculiarly affected in rheumatism. Thus, exposure to cold produces in one person catarrh, in another pneumonia, in another pleuritis, in another rheumatism, according to idiosyncrasy. Now, the parts affected in catarrh, pneumonia, pleuritis, however they may differ in density, are of the same nature with the tendinous aponeurosis of the joints and muscles, and the cellular substance interposed between their fibres. It is, therefore, not illogical to conclude, that it is the cellular membrane, not the muscular fibre, that is primarily and peculiarly affected in rheumatism. Not but that there must also be an affection of the muscular fibre; for, as has already been observed, the connection betwixt the two, the cellular substance and muscular fibre, is so intimate, that we cannot well conceive the former to be in a morbid state, and the latter remaining altogether sound. But we must repeat, that this affection of the muscular fibre is secondary, and therefore cannot be considered as constituting a proximate cause.
In the fifth place, Dr. Cullen has remarked, that the affection of the muscular fibres attending rheumatism, seems to explain why sprains and spasms produce rheumatic affection. That sprains and spasms frequently terminate in rheumatism, is an acknowledged fact. But this fact is no way explicable on the supposition of a peculiar affection, in that disease, of the muscular fibre. For it is not the muscular fibre that chiefly suffers in these accidents. The muscles are capable of acting with amazing force. They sometimes rupture their natural bandages; lacerate their tendons; and even the bones themselves have been broken by the violence of their action. It is not probable, therefore, that such powerful organs will be the first to yield in such a trial of strength as takes place in sprains, between them, their tendons, and tendinous aponeurosis. The fact is, that in cases of sprains, patients uniformly point to the situation of some aponeurosis, tendon, annular, capsular, or interosseous ligament, as the seat of debility and of pain. No conclusion, therefore, can be more natural, than that rheumatic affections arising from such accidents, are not affections chiefly of the muscular fibre, but of that substance which is of the same structure with the parts originally affected.
Finally. It would appear from the history of rheumatism, that the proximate cause, of the acute species at least, of that disease, is an affection of the aponeurotic expansion of the tendons and membranous covering of the joints. This appears from joints being first affected with pain, and its consequences. In many instances, indeed, the pain is confined entirely to the joints. At other times the muscles come to be affected with pains shooting along their course from one joint to another. But is it by the muscular fibre that these pains are propagated? Is it not more consonant with the other phenomena of the disease, to suppose that these pains are occasioned by the oscillation of the contents of the extreme vessels? It is ascertained, that when red blood is, in consequence of inflammation, forced into vessels that do not naturally admit it, resolution is effected by that blood taking a retrograde course, till it comes to vessels of sufficient calibre to transmit it; in inflammations of the eye, for example, and of the pleura. In the latter, no symptoms of inflammation have appeared, upon dissection, in cases which, previous to death, exhibited every symptom of it; a circumstance that can be explained only on the supposition of the reflux of the blood, after death, from the part affected. From this view, it is more than probable, that vessels so extremely minute, and so very irritable and contractile as are the capillaries of the aponeurosis and cellular membrane, are so affected, in rheumatism, as to be incapable of transmitting, as in health, the colourless part of the blood; which therefore, by its oscillations and pressure against the parietes of its vessels, occasions those pains, hitherto believed to be propagated from joint to joint, by the muscular fibre.
Independent of the primary affections of the joints, the very nature of the remote causes themselves renders it probable, that the proximate cause of acute rheumatism is an affection of the membranes connected with the muscles. Sudden changes of weather, the application of cold to the body when warm, cannot but affect those parts soonest, and to the greatest degree, that are most exposed to their operation; and the parts so exposed are, next to the extreme vessels of the skin, the aponeuroses of the joints and muscles. The powerful muscles of the larger joints, the most common seat of rheumatic affections, are svecessarily furnished with fasciæ, strong and dense, and whose vessels must, of course, be extremely minute. It is, therefore, a priori, to be expected, that they must suffer constriction from the application of cold to the body, sooner than vessels of less irritability and contractility, but of larger calibre.
But chronic is often the consequence of acute rheumatism. Nothing, therefore, can be more evident than that what constitutes the proximate cause of the latter must also form that of the former. For the only difference betwixt the two species of the disease consists in this, that the acute is accompanied with fever, whereas the chronic is free, or nearly free, from it. It necessarily follows, that, if a phlogistic diathesis of the blood, amounting to fever, and an affection of the aponeurosis and membranes of the joints and muscles, constitute the proximate cause of acute rheumatism, the chronic species of the disease must also acknowledge for its proximate cause, an affection, not different in nature though it may be in degree, of the same membranes and aponeuroses.
I was led into these speculations, near as they may approach, or far as they may be from the truth, by what occurred some time ago in my own person, and which I have often since practised upon others, with almost uniformly the same good effect. Having been seized with a rheumatic affection of the left shoulder, chiefly in the course of the deltoid muscle, the pain at times, but especially towards morning, when warm in bed, was so severe as to make me cry out. Desirous, on one of these occasions, of moving my arm, a task to which its own powers were unequal, I grasped it firmly with my right hand, about the middle of the pained muscle. To my surprise and high gratification I was instantly relieved from pain; and while I thus held my arm, I could do any thing with it I pleased without farther aid from my right hand than mere compression. This, therefore, was the remedy, the only remedy to which, on all future occasions of the kind, I had recourse, and it never was employed without success.
I now began to think, that surely the muscular fibre was not the seat of pain in rheumatism; not even to those pains occasioned by motion. if it were, how could mere compression enable it to contract with all its pristine vigour? I observed, VOL. VI.
moreover, that when, during the paroxysms of pain, I endeavoured to move my arm, the moment the belly of the muscle began to press on the aponeurosis, I was obliged to stop; but as soon as artificial resistance was opposed to it, the muscle could perform its functions with the utmost ease. A more decisive proof, I think, cannot be adduced, that the pain and difficulty of motion of a limb, afflicted with chronic rheumatism, are not referable to the muscular fibre. It may occur to the reader as it did to me, that the sudden relief from pain which I experienced, is to be explained on the principal of ligatures interrupting the progress of pain, or any other sensation, along the course of the nerves, as in some cases of epilepsy, whitlow, &c. But this by no means accounts for the fact. For I always remained free from pain for a considerable time after compression was removed. I find, upon inquiry, it is no uncommon thing for people afflicted with rheumatism, to grasp and nibble a pained joint or muscle, for the purpose of obtaining even temporary relief, which they never fail to procure in greater or less degree.
A very pertinent instance of the effects of compression occurred to me, on the 14th of November last. A woman twentyseven years old, and very much emaciated, complained of a rheumatic affection in her left shoulder, which had rendered her arm next to useless for many weeks. The pain was confined to the scapular portion of the deltoid muscle. She could by no means raise her arm to a right angle with the trunk of her body. She could not put her hand to her mouth, far less touch with the points of her fingers the crown of her head. Placing her before me on a form, I made gentle pressure with the palm of my hand on the pained part, desiring her, at the same time, to raise her hand to the crown of her head. This she could not do. I increased the pressure, and the motion of the arm became in proportion free. This process was continued till she could move her arm in every direction, with little or no uneasiness. What surprised the patient most was, she in a very short time became capable of using her arm, with nearly as much freedom without, as with the pressure.
How are these facts to be explained? Thus, in my opinion. The aponeurosis, and perhaps the whole cellular membrane of