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Clinical Lecture ON THE DIAGNOSIS OF DISEASES OF THE JOINTS.
FEBRUARY 12, 1859.
Clinical Lecture ON THE
DIAGNOSIS OF DISEASES OF THE JOINTS. Delivered
BY THOMAS
at
Guy’s Hospital,
BRYANT, ESQ., F.R.C.S.,
ASSISTANT-SURGEON AND SURGICAL REGISTRAR AT THE HOSPITAL.
(Concluded from
page
130.)
The bones and t7tei2- diseases next claim our attention, and it may be difficult to distinguish the form of dis. ease to which the bone may be subjected, it is not so to form In children, diseases of the joints, as an opinion as to its seat. a rule, originate in these structures, synovitis in them being remarkably rare; and it is in the bones that the disease generally commences. It is known by a gradual enlargement of the articular extremities, this enlargement being mostly preceded by local and wandering pains. Upon moving the joint, no signs of disease are evident, but firm pressure over the bone will generally be attended by some pain. The disease called strumous is the chief enemy to the bones of children; but if this name be confined, as I believe it should be, to those cases where a true strumous deposit may be present, it is exceedingly rare; for it is quite exceptional, after the removal of the part, to detect any such deposit; and I would much rather be disposed to regard the disease as inflammatory, in a child which is out of health, or which possesses or inherits the diathesis which is called strumous. It is as well in all cases to confine our terms to conditions which we all recognise, and not to apply them to pathological conditions unless a distinct and clear conception of those conditions is conveyed by the term so employed. As a general term, we all know what a strumous diathesis means; but when we apply it to a local condition, we only know it when the deposit called strumous is present. In these diseases of the joints its presence is quite exceptional; and as it is not now my intention to enter into the pathology of such affections, which I shall do at another time, and in another place, I only guard you against the erroneous idea which you may possess, or which you may fancy it is the intention of the surgeon to convey to you when he employs the term strumous disease of a joint, and would ask you to believe that it is only a chronic inflammatory condition of the bone in a strumous child; its pathology proves the truth of such an opinion, but at present I must only ask you to take it upon my authority. In other diseases of the bone, when occurring in adults, the diagnosis is not difficult. The joint is to a late period of the disease quite sound; the synovial membrane is also quite healthy, as proved by the absence of effusion; and by attention to the history of the disease, it will be clear that it is in the bone: whether that disease is malignant, myeloid, inflammatory, or strumous, is another question, and such diagnosis demands more general considerations. The disease, when it commences in the bone, and depends upon the development of some malignant, myeloid, or other tumour, is always of a gradual growth; the bone gradually expands, accompanied with more or less pain; and it is not till a late period of the disease that the mobility of the joint is involved-in fact, not until the bone has so enlarged as to interfere mechanically with the joint’s action; and it is rare that the joint becomes diseased at all. In inflammatory affections of the heads of bones, however, another tale must be told, for it is not possible for such disease to continue long without spreading to the neighbouring tissues, and the joint will sooner or later become involved. Such disease generally results from some blow or accident, but it may occur without any known cause. Acute or subacute pain may indicate its presence, and may remain for a long period, and the enlargement of the part may be slight, or nothing at all. The pain becomes at last of a throbbing character, indicating the presence of pus. As a rule, this pus, accompanied
although
quence, acute synovitis, with rapid disorganization of the cartilages and joint, is the result. Occasionally, however, the abscess, &c., open externally, as indicated by a sinus leading down to the diseased bone; but this seldom impedes the progress of the disease jointwards, and a similar result follows. I know of no case more painful to watch as a surgeon than necrosis of the articular extremity of bones. To interfere is almost always to hasten on what we wish to postpone-viz., disintegration of a joint; and I know of few instances where such interference was followed by success, but I could mention many where a very different result followed. Of course I except the cases of circumscribed abscess of the heads of bones. The strumous disease of the bone, or rather the chronic inflammatory disease occurring in a strumous subject, is always of a very chronic character; it may continue for years, and consequently offers a fair chance of success in its treatment. The bone expands but gradually, and its attendant pain is but slight; mobility of the joint does not produce pain, but mobility and pressure, as in walking, do. If arrested by treatment, all goes on well, and a perfect recovery may ensue; but if allowed to pursue its course, the other structures of the joint are certain to become involved sooner or later, and, as a consequence, the. hope of a cure becomes less certain. We must now pass on, and make some few remarks upon the diagnosis of disease of the cartilage, and I can only regret that the information I can give you is so slight and so uncertain. As a primary disease, I am led to believe, in studying its pathology, that such may exist, but I cannot give you any diagnostic marks by which it may be recognised during life. In some cases a vague and wandering pain about a joint, unattended with any effusion or signs of disease of a bone, may perhaps indicate that form of degeneration which, in a small pamphlet upon the subject, I have described as the fibrous; and in occasional cases, severe pain, followed by rapid disor. ganization of a joint, may be accompanied with the granular disease of the cartilage; but as a primary disease this is remarkably rare, and I am unable to give you any other means of
diagnosis. As a secondary disease, the cartilages are invariably involved; for no disease can progress far in the bones or synovial membrane without necessarily involving the articular cartilages. In chronic disease of the heads of bones not involving their
articular surfaces, in chronic disease of the cellular membrane about joints, and in other cases where the joint has been unemployed for long periods, the cartilage, like other tissues, will certainly undergo the fatty degeneration, or atrophy. In chronic disease of the synovial membrane and articular ends of bones, where the nutrition of the cartilage must necessarily suffer, the granular degeneration of the cartilage is more likely to result; and the reason for this is found in the method by which the articular cartilages are nourished. In the pamphlet previously alluded to, I have described how the articular cartilages are supplied with nourishment, through the vessels which supply the articular extremity of the bones to which they are applied, and also through the synovial membrane, no vessels passing into the structure itself; and I there stated " it is clear that structures deriving nourishment through other, although adjacent tissues, must depend much upon the integrity of those tissues; and that if any disturbing cause should arise to prevent or arrest their powers of nutrition, the same, if not increased, perversion of nutrition must ensue in the tissues thus secondarily supplied; and in the cartilages of joints such a result may be most admirably witnessed."" It is easily understood, then, how the cartilages are involved and become diseased in chronic or acute affections of the bones and synovial membranes, and how the symptoms which mark the progress of the disease in them are masked by the primary and more important disease in the tissues upon the integrity of which they depend for their supply of nourishment. The want of diagnostic signs will then be easily understood, and the reason for the scanty information which I am able to give you satisfactorily explained. But remember that as long as the cartilages of joints are entire and undiseased, the joint, as a joint, still exists in its integrity, and the hope of perfect recovery may still be entertained; and let this fact be impressed upon your minds, and stimulate you to attend with care and promptitude to any early disease of a joint, as it is only by arresting it in such a stage that a joint may be preserved. I havenow indicated to you the principal points which, if regarded, will generally enable you to diagnose the form of disease to which a joint may be liable, and as clearly as I am able I havepointed out the landmarks by which some of the diswith necrosed bone, which is generally the result of the inflam- eases of the different tissues may be recognised. But there are matorv process, finds its wav into the ioint. and. as a conse- other cases which are not so easy to recognise, and which can
No. 1850.
that
0
only be made out by careful study. The pulpy degene7-atioii of of much carelessness upon your own part. But, before conthe synovial membrane, as described by Sir B. Brodie, is one of cluding, let me try to impress upon you one point of great them; and although the surgeon may in some cases form a importance, and one which you should always attempt to reatolerably correct opinion as to its existence, these cases are ob- lize and to follow, as it will prove of immense value to you in scure in their origin and in their progress. When this disease the diagnosis of disease, as well as in its treatment-and it is is present, you will find its progress has been very gradual, and it has not been attended with much pain or tenderness; the bones will appear natural, and not enlarged ; there will not be any fluctuation or other symptom of fluid within the joint,I in its early stage the cellular tissue and integument will appear healthy and uninvolved, although at a later period it may become implicated; yet the joint, as a whole, is evidently enlarged. To the hand it gives a soft and yielding feel, especially in parts between the bones, and therefore directly over the joint and synovial membrane. This pressure will also produce an impression of elasticity, and will be somewhat peculiar to I the disease. Upon the whole, these symptoms are tolerably characteristic, and, if present, should lead you to expect the presence of that disease called the pulpy degeneration of the synovial membrane. It is not, however, a common affection. There is another disease of the synovial membrane, which I believe is more generally mistaken for the preceding, and pathologically depends upon a ch1’onic inflammation. The synovial membrane inflames and pours out a little serum, but This fibrinous effusion organizes more organizable materials. and forms a membrane upon the inner surface of the synovial membrane; a second and third layer may follow at short intervals, and the synovial membrane itself becomes considerably thicker, the same material becoming infiltrated, as it were, between its fibres. As a result, the membrane, with its new product, becomes considerably thickened, sometimes to the extent of an inch or more, and in rare cases almost filling up the joint. The progress of this disease is not unlike that which we see in chronic inflammation of the bursa patellas, when the bursa thickens by frequent deposits of fibrinous material, and I
this: In all cases of disease which you are called upon to treat, and more especially in the diseases of joints, regard the part at first purely pathologically; attempt to realize the xnnrof its different structures; recall the process by bid which structure has deviated from its healthy state; and to bring before your mental eye the present condition of the diseased structure. So that recognising the process by which the tissue has erred from its state’ of health, and, as it were, handling the part, and carefully examining its present condition, you can apply your remedy with greater certainty,4 and will do so with greater success. This plan of regarding disease increases much your interest in every case, makes the practice of the surgical profession a science, and removes it from the mere character of an art; for, instead of (like the empiric) treating symptoms alone, you direct your treatment to the causes which produce them, and. as a consequence, will become a more successful practitioner.
conditions
attempt each
ON
A CASE IN WHICH THE OPERATION OF
CASTRATION WAS RESORTED TO FOR THE CURE OF EPILEPSY. BY
JOHN
W.
OGLE, M.D., F.R.C.P.,
ASSISTANT-PHYSICIAN TO ST.
GEORGE’S
HOSPITAL.
MANY will have read with much interest the history of the in which Mr. Holthouse lately removed both testicles for the cure of epilepsy, as described in THE LANCET of the 22nd ult. The details of the case are so important, and the treattory, it is distinct. You will find that there have existed at ment adopted so novel, that, being in possession of some pardifferent intervals several attacks of inflammation, accompanied with effusion and its symptoms; and the progress, instead ticulars connected with it beyond what are given in that hisof being gradual and uniform, will be broken by the inflamma- tory, I venture to make them known. The patient who has undergone this operation came under tory attacks and their attendant symptoms. We will now pass on to a later period of the diseases of a my notice in June, 157. He had been for many years under joint; and disregarding for the present the seat of the original medical treatment in America, his native country; after which disorder, we shall find a joint presenting all the symptoms of what was called a " white swelling." This term is certainly time he had been in England for a short period.He then visited Paris, where he was under medical care; and it was a general one, and far too general for scientific men to employ to one another. It is useful to employ when we must give a after his sojourn in Paris that I saw him, and learnt the circumname to a disease which we are treating, for the public and his case, which, in most reuninitiated will have a distinct name applied to their disease; stances-revolting enough-of with those summed up so well by closely spects, corresponded and it must, therefore, be classed with such words as a tumour, Mr. P. Adair, in THE LANCET. a dropsy, an inflammation, and such-like general terms. On one or two points, however, the particulars which 1 It is the last stage, or nearly so, of a chronic disease of a and which I took at the time in writing, are more exteiicommenced in the whether that disease have, bones, synovial joint, membrane, or cartilages. All of them are involved to a greater sive than those given in THE IjANCET. In the first place, or less extent, this extent depending upon the original seat of although degrading and debilitating habits had been contracted the disorder. The external tissues have not escaped the general by the unfortunate patient at the commencement of his attacks influence; and the skin is found firm, stretched, and immov- (when but ten years old), yet, as he informed me, his disease able. The cellular tissue is infiltrated with inflammatory pro- was at the time attributed to disturbance consequent on his Before this ducts, and the joint will generally present a hard, uniform, eating green fruit in too large an abundance. " and tense swelling; the bones will be recognised, but not dis- period also, he had been the subject of prolapsus ani;" and; of my observation, he had frequently tinctly, their outlines being lost in the general infiltration. indeed, up to the time There will not, as a rule, be any distension of the synovial had this prolapsus, and also occasional bleedings by the rectum. membrane; but this will be thickened both in itself and by All this points to the supposition that intestinal irritation may deposit upon its inner surface. If there is any mobility of the at any rate have co-operated, with other causes, in giving joint, the peculiar crepitation of exposed bone will be detected; origin to, and keeping up, a predisposition to epileptic seizures. As respects the character of the seizures themselves, the and this will also be present if the patella can be at all moved. This symptom sufficiently indicates the degeneration and ab- patient stated that at the outset (i. e., about the year 1825), sorption of the articular cartilages. Upon the whole, it would i they were of about half an hour’s duration, and were attended appear we if all distinction between the tissues had disappeared, by much struggling and foaming at the mouth, and biting of and that a different structure had been deposited. The joint the tongue, and that they gradually increased in number and strength up to the year 1834, when, owing to the use of nitrate may, and will, in some cases, present many fistulous either communicating with the joint or with one of its diseased of silver, which he took daily for several months, and eventutissues, these nstulse being merely the remains of old abscesses ally at the rate of half a grain three times a day, they began in the part, and leading either into the joint or into the dis- to diminish. The attacks, which almost invariably occurred in the day time, generally were followed by much headache or eased articular extremities of the bones. I have now cursorily run over the chief points which mark in THE LANCET, this patient came to England * According to the the principal diseases of the joints, and have pointed out to on this occasion to history have tracheotomy performed, following the advice oi’ seen him in America. This I can hardly underDr. Marshall who had be considered as Hall, you the symptoms which may diagnostic of as it appears that when Dr. M. Hall saw him in America, at which time their different diseases. If you impress these upon your memory, stand, his larynx, his attacks were quite mild Dr. Horace Greene was I can hardly say you will never fall into an error of diagnosis, comparatively, and quitecauterizing free from anything like laryngismus-the only syn’prender would but I believe that it will be rare, and that it must be the result tom which tracheotomy advisable.
whfn at la.st it
mav
befnmc almost soUd-
Upon examining a joint affected with this disease, the manipular indications are not unlike those which are presented by the disease previously described; but by attending to the his-
case
openings,
156
Clinical Lecture ON THE
DIAGNOSIS OF DISEASES OF THE JOINTS. Delivered
BY THOMAS
at
Guy’s Hospital,
BRYANT, ESQ., F.R.C.S.,
ASSISTANT-SURGEON AND SURGICAL REGISTRAR AT THE HOSPITAL.
(Concluded from
page
130.)
The bones and t7tei2- diseases next claim our attention, and it may be difficult to distinguish the form of dis. ease to which the bone may be subjected, it is not so to form In children, diseases of the joints, as an opinion as to its seat. a rule, originate in these structures, synovitis in them being remarkably rare; and it is in the bones that the disease generally commences. It is known by a gradual enlargement of the articular extremities, this enlargement being mostly preceded by local and wandering pains. Upon moving the joint, no signs of disease are evident, but firm pressure over the bone will generally be attended by some pain. The disease called strumous is the chief enemy to the bones of children; but if this name be confined, as I believe it should be, to those cases where a true strumous deposit may be present, it is exceedingly rare; for it is quite exceptional, after the removal of the part, to detect any such deposit; and I would much rather be disposed to regard the disease as inflammatory, in a child which is out of health, or which possesses or inherits the diathesis which is called strumous. It is as well in all cases to confine our terms to conditions which we all recognise, and not to apply them to pathological conditions unless a distinct and clear conception of those conditions is conveyed by the term so employed. As a general term, we all know what a strumous diathesis means; but when we apply it to a local condition, we only know it when the deposit called strumous is present. In these diseases of the joints its presence is quite exceptional; and as it is not now my intention to enter into the pathology of such affections, which I shall do at another time, and in another place, I only guard you against the erroneous idea which you may possess, or which you may fancy it is the intention of the surgeon to convey to you when he employs the term strumous disease of a joint, and would ask you to believe that it is only a chronic inflammatory condition of the bone in a strumous child; its pathology proves the truth of such an opinion, but at present I must only ask you to take it upon my authority. In other diseases of the bone, when occurring in adults, the diagnosis is not difficult. The joint is to a late period of the disease quite sound; the synovial membrane is also quite healthy, as proved by the absence of effusion; and by attention to the history of the disease, it will be clear that it is in the bone: whether that disease is malignant, myeloid, inflammatory, or strumous, is another question, and such diagnosis demands more general considerations. The disease, when it commences in the bone, and depends upon the development of some malignant, myeloid, or other tumour, is always of a gradual growth; the bone gradually expands, accompanied with more or less pain; and it is not till a late period of the disease that the mobility of the joint is involved-in fact, not until the bone has so enlarged as to interfere mechanically with the joint’s action; and it is rare that the joint becomes diseased at all. In inflammatory affections of the heads of bones, however, another tale must be told, for it is not possible for such disease to continue long without spreading to the neighbouring tissues, and the joint will sooner or later become involved. Such disease generally results from some blow or accident, but it may occur without any known cause. Acute or subacute pain may indicate its presence, and may remain for a long period, and the enlargement of the part may be slight, or nothing at all. The pain becomes at last of a throbbing character, indicating the presence of pus. As a rule, this pus, accompanied
although
quence, acute synovitis, with rapid disorganization of the cartilages and joint, is the result. Occasionally, however, the abscess, &c., open externally, as indicated by a sinus leading down to the diseased bone; but this seldom impedes the progress of the disease jointwards, and a similar result follows. I know of no case more painful to watch as a surgeon than necrosis of the articular extremity of bones. To interfere is almost always to hasten on what we wish to postpone-viz., disintegration of a joint; and I know of few instances where such interference was followed by success, but I could mention many where a very different result followed. Of course I except the cases of circumscribed abscess of the heads of bones. The strumous disease of the bone, or rather the chronic inflammatory disease occurring in a strumous subject, is always of a very chronic character; it may continue for years, and consequently offers a fair chance of success in its treatment. The bone expands but gradually, and its attendant pain is but slight; mobility of the joint does not produce pain, but mobility and pressure, as in walking, do. If arrested by treatment, all goes on well, and a perfect recovery may ensue; but if allowed to pursue its course, the other structures of the joint are certain to become involved sooner or later, and, as a consequence, the. hope of a cure becomes less certain. We must now pass on, and make some few remarks upon the diagnosis of disease of the cartilage, and I can only regret that the information I can give you is so slight and so uncertain. As a primary disease, I am led to believe, in studying its pathology, that such may exist, but I cannot give you any diagnostic marks by which it may be recognised during life. In some cases a vague and wandering pain about a joint, unattended with any effusion or signs of disease of a bone, may perhaps indicate that form of degeneration which, in a small pamphlet upon the subject, I have described as the fibrous; and in occasional cases, severe pain, followed by rapid disor. ganization of a joint, may be accompanied with the granular disease of the cartilage; but as a primary disease this is remarkably rare, and I am unable to give you any other means of
diagnosis. As a secondary disease, the cartilages are invariably involved; for no disease can progress far in the bones or synovial membrane without necessarily involving the articular cartilages. In chronic disease of the heads of bones not involving their
articular surfaces, in chronic disease of the cellular membrane about joints, and in other cases where the joint has been unemployed for long periods, the cartilage, like other tissues, will certainly undergo the fatty degeneration, or atrophy. In chronic disease of the synovial membrane and articular ends of bones, where the nutrition of the cartilage must necessarily suffer, the granular degeneration of the cartilage is more likely to result; and the reason for this is found in the method by which the articular cartilages are nourished. In the pamphlet previously alluded to, I have described how the articular cartilages are supplied with nourishment, through the vessels which supply the articular extremity of the bones to which they are applied, and also through the synovial membrane, no vessels passing into the structure itself; and I there stated " it is clear that structures deriving nourishment through other, although adjacent tissues, must depend much upon the integrity of those tissues; and that if any disturbing cause should arise to prevent or arrest their powers of nutrition, the same, if not increased, perversion of nutrition must ensue in the tissues thus secondarily supplied; and in the cartilages of joints such a result may be most admirably witnessed."" It is easily understood, then, how the cartilages are involved and become diseased in chronic or acute affections of the bones and synovial membranes, and how the symptoms which mark the progress of the disease in them are masked by the primary and more important disease in the tissues upon the integrity of which they depend for their supply of nourishment. The want of diagnostic signs will then be easily understood, and the reason for the scanty information which I am able to give you satisfactorily explained. But remember that as long as the cartilages of joints are entire and undiseased, the joint, as a joint, still exists in its integrity, and the hope of perfect recovery may still be entertained; and let this fact be impressed upon your minds, and stimulate you to attend with care and promptitude to any early disease of a joint, as it is only by arresting it in such a stage that a joint may be preserved. I havenow indicated to you the principal points which, if regarded, will generally enable you to diagnose the form of disease to which a joint may be liable, and as clearly as I am able I havepointed out the landmarks by which some of the diswith necrosed bone, which is generally the result of the inflam- eases of the different tissues may be recognised. But there are matorv process, finds its wav into the ioint. and. as a conse- other cases which are not so easy to recognise, and which can
No. 1850.
that
0
only be made out by careful study. The pulpy degene7-atioii of of much carelessness upon your own part. But, before conthe synovial membrane, as described by Sir B. Brodie, is one of cluding, let me try to impress upon you one point of great them; and although the surgeon may in some cases form a importance, and one which you should always attempt to reatolerably correct opinion as to its existence, these cases are ob- lize and to follow, as it will prove of immense value to you in scure in their origin and in their progress. When this disease the diagnosis of disease, as well as in its treatment-and it is is present, you will find its progress has been very gradual, and it has not been attended with much pain or tenderness; the bones will appear natural, and not enlarged ; there will not be any fluctuation or other symptom of fluid within the joint,I in its early stage the cellular tissue and integument will appear healthy and uninvolved, although at a later period it may become implicated; yet the joint, as a whole, is evidently enlarged. To the hand it gives a soft and yielding feel, especially in parts between the bones, and therefore directly over the joint and synovial membrane. This pressure will also produce an impression of elasticity, and will be somewhat peculiar to I the disease. Upon the whole, these symptoms are tolerably characteristic, and, if present, should lead you to expect the presence of that disease called the pulpy degeneration of the synovial membrane. It is not, however, a common affection. There is another disease of the synovial membrane, which I believe is more generally mistaken for the preceding, and pathologically depends upon a ch1’onic inflammation. The synovial membrane inflames and pours out a little serum, but This fibrinous effusion organizes more organizable materials. and forms a membrane upon the inner surface of the synovial membrane; a second and third layer may follow at short intervals, and the synovial membrane itself becomes considerably thicker, the same material becoming infiltrated, as it were, between its fibres. As a result, the membrane, with its new product, becomes considerably thickened, sometimes to the extent of an inch or more, and in rare cases almost filling up the joint. The progress of this disease is not unlike that which we see in chronic inflammation of the bursa patellas, when the bursa thickens by frequent deposits of fibrinous material, and I
this: In all cases of disease which you are called upon to treat, and more especially in the diseases of joints, regard the part at first purely pathologically; attempt to realize the xnnrof its different structures; recall the process by bid which structure has deviated from its healthy state; and to bring before your mental eye the present condition of the diseased structure. So that recognising the process by which the tissue has erred from its state’ of health, and, as it were, handling the part, and carefully examining its present condition, you can apply your remedy with greater certainty,4 and will do so with greater success. This plan of regarding disease increases much your interest in every case, makes the practice of the surgical profession a science, and removes it from the mere character of an art; for, instead of (like the empiric) treating symptoms alone, you direct your treatment to the causes which produce them, and. as a consequence, will become a more successful practitioner.
conditions
attempt each
ON
A CASE IN WHICH THE OPERATION OF
CASTRATION WAS RESORTED TO FOR THE CURE OF EPILEPSY. BY
JOHN
W.
OGLE, M.D., F.R.C.P.,
ASSISTANT-PHYSICIAN TO ST.
GEORGE’S
HOSPITAL.
MANY will have read with much interest the history of the in which Mr. Holthouse lately removed both testicles for the cure of epilepsy, as described in THE LANCET of the 22nd ult. The details of the case are so important, and the treattory, it is distinct. You will find that there have existed at ment adopted so novel, that, being in possession of some pardifferent intervals several attacks of inflammation, accompanied with effusion and its symptoms; and the progress, instead ticulars connected with it beyond what are given in that hisof being gradual and uniform, will be broken by the inflamma- tory, I venture to make them known. The patient who has undergone this operation came under tory attacks and their attendant symptoms. We will now pass on to a later period of the diseases of a my notice in June, 157. He had been for many years under joint; and disregarding for the present the seat of the original medical treatment in America, his native country; after which disorder, we shall find a joint presenting all the symptoms of what was called a " white swelling." This term is certainly time he had been in England for a short period.He then visited Paris, where he was under medical care; and it was a general one, and far too general for scientific men to employ to one another. It is useful to employ when we must give a after his sojourn in Paris that I saw him, and learnt the circumname to a disease which we are treating, for the public and his case, which, in most reuninitiated will have a distinct name applied to their disease; stances-revolting enough-of with those summed up so well by closely spects, corresponded and it must, therefore, be classed with such words as a tumour, Mr. P. Adair, in THE LANCET. a dropsy, an inflammation, and such-like general terms. On one or two points, however, the particulars which 1 It is the last stage, or nearly so, of a chronic disease of a and which I took at the time in writing, are more exteiicommenced in the whether that disease have, bones, synovial joint, membrane, or cartilages. All of them are involved to a greater sive than those given in THE IjANCET. In the first place, or less extent, this extent depending upon the original seat of although degrading and debilitating habits had been contracted the disorder. The external tissues have not escaped the general by the unfortunate patient at the commencement of his attacks influence; and the skin is found firm, stretched, and immov- (when but ten years old), yet, as he informed me, his disease able. The cellular tissue is infiltrated with inflammatory pro- was at the time attributed to disturbance consequent on his Before this ducts, and the joint will generally present a hard, uniform, eating green fruit in too large an abundance. " and tense swelling; the bones will be recognised, but not dis- period also, he had been the subject of prolapsus ani;" and; of my observation, he had frequently tinctly, their outlines being lost in the general infiltration. indeed, up to the time There will not, as a rule, be any distension of the synovial had this prolapsus, and also occasional bleedings by the rectum. membrane; but this will be thickened both in itself and by All this points to the supposition that intestinal irritation may deposit upon its inner surface. If there is any mobility of the at any rate have co-operated, with other causes, in giving joint, the peculiar crepitation of exposed bone will be detected; origin to, and keeping up, a predisposition to epileptic seizures. As respects the character of the seizures themselves, the and this will also be present if the patella can be at all moved. This symptom sufficiently indicates the degeneration and ab- patient stated that at the outset (i. e., about the year 1825), sorption of the articular cartilages. Upon the whole, it would i they were of about half an hour’s duration, and were attended appear we if all distinction between the tissues had disappeared, by much struggling and foaming at the mouth, and biting of and that a different structure had been deposited. The joint the tongue, and that they gradually increased in number and strength up to the year 1834, when, owing to the use of nitrate may, and will, in some cases, present many fistulous either communicating with the joint or with one of its diseased of silver, which he took daily for several months, and eventutissues, these nstulse being merely the remains of old abscesses ally at the rate of half a grain three times a day, they began in the part, and leading either into the joint or into the dis- to diminish. The attacks, which almost invariably occurred in the day time, generally were followed by much headache or eased articular extremities of the bones. I have now cursorily run over the chief points which mark in THE LANCET, this patient came to England * According to the the principal diseases of the joints, and have pointed out to on this occasion to history have tracheotomy performed, following the advice oi’ seen him in America. This I can hardly underDr. Marshall who had be considered as Hall, you the symptoms which may diagnostic of as it appears that when Dr. M. Hall saw him in America, at which time their different diseases. If you impress these upon your memory, stand, his larynx, his attacks were quite mild Dr. Horace Greene was I can hardly say you will never fall into an error of diagnosis, comparatively, and quitecauterizing free from anything like laryngismus-the only syn’prender would but I believe that it will be rare, and that it must be the result tom which tracheotomy advisable.
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Upon examining a joint affected with this disease, the manipular indications are not unlike those which are presented by the disease previously described; but by attending to the his-
case
openings,
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