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REMARKS ON THE INFLAMMATION AND BLOODLETTING CONTROVERSY.
while, therefore, we fully appreciate the direct application of pathological anatomy to the identification of internal causes when revealed only after death, we must also acknowledge its special application to diagnosis through signs, physical, chemical, and structural, thus afforded during life.
able to a due knowledge of pathological anatomy; and therefore to this source is also due the prevention of secondary ulceration of articular cartilage. This ANTICIPATION of secondary disease through the timely identification and removal of its structural, or internal cause, fulfils the HIGHEST APPLICATION of PATHOLOGICAL ANATOMY to
If, however, pathological anatomy can alone verify internal THERAPEUTICS. But concurrently with ulceration from caries, and more of disease and injury, let us further examine the conseadmission. We shall thus discover more fully rarely from synovitis, we observe more general consequences quences of this The heart beats feebly, or at least irregularly, and the ensue. the intimate relations of that science to therapeutics. For this purpose I would select inflammatory diseases of the pulse is therefore weak and fickle; the respiration becomes joints, which present in themselves ample illustrations of hurried; the organs of digestion soon sympathise, for the apinternal causes and their consequences. petite fails, and diarrhoea ensues; whilst the skin pours forth Observe, then, commencing synovitis -say of the knee-joint. abundantly the night-sweats of hectic fever, and the urine We discover a painful spot, and this spreading gradually over deposits its lithates as the body wastes and the strength de-the whole articulation. Very shortly, a fluid and fluctuating clines. The early detection and removal of either cause in swelling supervenes, the shape of which, although that of the operation prior to suppuration, would assuredly have alike distended synovial capsule, is yet, with its size, also influenced prevented not only adjacent structural disease-ulceration of by the compression of surrounding ligaments and tendons. If cartilage, but also these disturbances of 1’emotefunct’iol1s. In like manner we may not only anticipate the adjacent and now the joint were opened, and the synovial.membrane exposed, we should observe its undue vascularity, of a more or remote consequences of disease, but prevent also destructive less scarlet colour, and that perhaps some blood had actually results in those tissues where the disease originated. We escaped, tinging thereby the serum and lymph also effused must thus distinguish results from consequences. A consewithin the capsule, which with these contents together form quence is that which follows after a previous condition, which the fluctuating and elastic swelling of acute synovitis. At may itself have disappeared. A result is not merely an effect, this early period the synovial membrane still retains its usual but may be considered the final sequent, or termination of one thinness and pliancy. It may, however, happen that pus is and the same condition, itself persistent. If, thus, the prosubsequently poured out within the joint, and, concurrently gress of synovitis be not speedily arrested, that condition will with such an effusion, the cartilages lose their substance, as if almost invariably terminate in chronic thickening and induraulcerated. Here, then, we trace the extension of pus-forming tion of the capsule. Again, if scrofulous caries of the tibia run its course, then the cancellated bone softens and disintegrates; synovitis to disintegration of the neighbouring cartilages. The removal of the primary synovitis would therefore, in the reddish serum within the cancelli is replaced by an albumithis instance, have actually prented disease of an adjoi2lil?g nous, granular, cheesy substance; whilst neighbouring cartilages tissue. This ANTICIPATION of disease, through the early detec- disappear, and the joint collapses. In either case the function tion of an internal cause in operation, is also illustrated by the of the part affected is entirely sacrificed—whether that of the history of scrofulous caries; but its practical application is less synovial membrane, now thickened and inflexible, or that of satisfactory than to synovitis. For the more early structural the articulation itself,—from the permanent and total dischanges of scrofulous caries are less apparent, and their progress organisation of chronic caries. This result-perhaps the irretherefore more insidious. Indeed, we do not at first observe parable loss of function-might certainly have been prevented any well-marked external sign of internal disorganization, and by the early recognition and removal of its structuralcause; are only induced by the equivocal (functional) symptoms of whilst its immediate effect—that of impaired function—may pain and lameness to suspect the destructive process going on also be restored by the timely removal of the structural cause within the bone. Pathology, therefore, does more than with which it is conjoined. For the present, time will not permit me to pursue this pathological anatomy to aid our diagnosis of incipient caries. Yet this assistance is but little. The pain in the head of the enquiry further; but in my next communication I shall present tibia, for instance, may at first be only trifling, perhaps inter- a summary of this paper, and then trace the argument on to mittent, yet fixed ; aggravated also on percussion of the joint, further results. causes
and increasing as the disease progresses. If now the cancellated bone were examined, we might observe its consistence softened, and the cancelli filled with reddish serum; but no further destructive change may as yet have ensued. Weeks, or perhaps months, may pass away before the puffy and elastic swelling of soft tissues around the joint arrests our serious attention. At length, however, the uniform and characteristic shape, no less than the enlargement also of the articulation—rendered even more apparent by the emaciation and semi-flexed position of the limb-together corroborate our diagnosis; perhaps only to be confirmed, when too late, by the friction of the articular surfaces, now denuded of their cartilage, and by undue mobility, or perchance fixed dislocation, of the joint when thus loosened and disorganized. If, then, the conseqxce;2ces of scrofulous caries are so disastrous, its early removal is the more imperative. The destruction of articular cartilage is, indeed, a more frequent conse.quent of this cause than of pus-forming synovitis; but, on reviewing the history of both caries and synovitis, it would appear that inflammation affecting the tissues of joints usually begins peripherally, and proceeds inwards to deeper parts. The primary ulceration of articular cartilage is, in fact, of com. paratively rare occurrence. Weshould therefore be prepared to discover some traces, at least, of previous inflammatory vascularity, in either the synovial membrane or in the cancellated bone, adjoining those cartilages which have been subsequently involved. If, then, the ulceration of articular cartilage is mostly of secondary occurrence to either caries or synovitis, it must be obvious that, by our early detection and removal of either disease when present, we may reasonably hope also to prevent a consequence so fatally destructive of the articulation. Now the carliest unequivocal sign of synovitis and caries is that of swelling, the precise nature of which, like that of other tumours, may be further determined by the examination of its contents, procured by puncture with a grooved needle. Thus the early recognition and interpretation of swelling are refer-
REMARKS ON THE
INFLAMMATION AND BLOODLETTING CONTROVERSY. BY W. O.
MARKHAM, M.D., F.R.C.P.,
PHYSICIAN TO ST.
MARY’S
HOSPITAL.
(Continued from p. 441.) FiRST of all, then, let us consider the nature of the evidence which has been offered in favour of this assumed change in the type of disease. By change in the type of disease is meant, asunderstand it, not a change in the essential nature of the disease itself, but a change in the condition of the body which is the subject of the disease. Pneumonia, for instance, is the same disease now, in so far as its anatomical characters are concerned, as pneumonia ever was, but the body in which the inflammation manifests itself is changed. The general diathesis of human nature has undergone some gradual alteration, so that the reaction of disease upon man is different now from what it was in the good old times, all which is proved by the fact that men did bleed in those times, but that they don’t bleed now; that bleeding was requisite once, but superfluous, and even dangerous, now. This change, moreover, is not a partial one; the entire human race it would appear has probably suffered the novel phasis. Not here only, but at the antipodes likewise, men no longer bear the bleedings they were once
beneficially subjected to.
From this it appears that the fact of an assumed change of type in disease rests mainly upon the circumstance that dis-
465
eases, having the same anatomical characters, receive at the cases of slighter kinds of pneumonia, with ill-marked and not present moment a vastly different method of cure from what urgent symptoms, (whose existence is revealed only through they did in former times; that formerly they presented sthenic the stethoscope,) recovered without bleeding, "just as they characters, but that now inflammation is asthenic. It is worthy may have done of late years under homœopathic treatment, and of remark here, incidentally, that Dr. Watson’s ideas of the often without the aid of stimulants." To such cases, indeed, change of type in disease differ in some respects from those of in former times, the name of pneumonia would not have been Some of them," Dr. Alison says, "am convinced Dr. Alison. Dr. Alison seems to conclude that for 2000 years given. inflammations have required large venesection, and now only were regarded in former times as fevers, of different denominasince the beginning of the present century have no longer the tions, and were treated as idiopathic fevers of the time and These slight pneumonias, it appears, were treated characters w hich demand it. Dr. Watson, on the other hand, place." "is firmly persuaded that there are waves of time through in those days as we treat them now--without bleeding. We which the sthenic and asthenic characters of disease prevail in know them, by stethoscopic signs, to be pneumonia; the succession, and that we are at present living amid one of its ancients knew them not as such, because auscultation was un. "
adynamic phases." This persuasion Dr. Watson derives from own personal experience, and from facts recorded in the history of medicine. Of course, also, it is assumed, as an un-
known. If this be true-that is, if pneumonia was only known in former days by certain urgent symptoms, and if the cases of doubted fact, that the treatment of former times was correct, pneumonia were rare in which these urgent symptoms preand that the treatment of the present time (however opposite) sented themselves-then pneumonia (as we understand the is also correct. term) must have been a disease rarely treated by bloodletting Now one may surely, on the threshold of the subject, be ex- in former times. Paradoxical as this may appear, it seems to cused if one feels sceptical concerning a fact of so extraordinary me to be the only conclusion at which we can arrive, according a kind; and surely no one can be blamed if he demand, before to Dr. Alison’s own showing. The rare and exquisite case of accepting the proposition, some clear and undeniable evidence pneumonia they recognised, and they bled it; the numerous of its correctness. Bleeding-the assertion is-from the time every-day cases of pneumonia, in which no urgent symptoms of Hippocrates down to the days of Cullen and Gregory, has marked the malady, and which only stethoscopy could define, been practised as the true cure for inflammations, and rightly were unrecognised, and were unbled Then as Now. But if this be true, how are we to account for the frequent practised; for upwards of 2000 years diseases have been sthenic. Bleeding, in these latter days, has not been practised, and and large bloodlettings which our forefathers are said to have rightly so; inflammations for, say, thirty years past, have been perpetrated in pneumonia ? The answer, I fancy, is satisfactory asthenic! The astonishing conclusion involved in the propo- enough ; it is to be found in the meaning attached by them to sition might almost justify one in doubting its correctness; and the term pneumonia. This meaning has, I am inclined to think, certainly of the two alternatives, I should think it as easy to not been always sufficiently kept in view by those who have believe that doctors have been for 2000 years bleeding in vain, discussed this subject of Inflammation and its Treatment. as that now for the first time disease has begun to show a Pneumonia, as we have said, meant in Cullen’s mind, inflam. changeful aspect, after having maintained an unaltered type mation of the Inngs, plenritis, bronchitis, endocarditis, peri. for 2000 years. I will now endeavour to show what sort of carditis, and doubtless many other affections of the thoracic evidence this proposition is founded on. organs. Dr. Gregory* says : ’’ There are several different names given A little consideration of the subject will show us, that the only way by which we can hope to arrive at any rational and to the Diseases in the Thorax, as the inflammation attacks difsatisfactory conclusion concerning it, is by a comparison of the ferent viscera, as the pleura, lungs, mediastinum, diaphragm, nature of inflammatory diseases in former days, and the results or pericardium, but all these are so connected that it is difficult of treatment employed for their cure, with similar diseases and to make a proper distinction. The peripneumony sometimes their cures, as observed by ourselves at the present time. Is it happens by itself, but I believe this is never the case with the possible to obtain such a comparison ? I cannot think that it inflammation of the other four viscera ; and, besides, from the is. Our knowledge of the pathology of diseases and our dia- symptoms, it is almost impossible to say what part is affected. gnosis have undergone a complete revolution; and, oddly The treatment is pretty much the same in all. On this account enough, it is well to remark, the revolution seems to have I shall consider them altogether, and if anything particular occurred at a somewhat similar moment to that in which the occurs to any one, mention it separately." From all this, it appears clear, that the diseased conditions reputed change of type in disease was effected. The knowledge which we possess of the nature and progress of internal inflam- for which these large bleedings are said to have been practised, mations-all must admit-is vastly superior to, and different and which were comprised by Cullen under the generic term from, that which our forefathers possessed. When Cullen Pneumonia, included all those affections, of whatsoever nature, speaks of pneumonia, he means, "the whole of the inflamma- which give rise to certain special symptoms-viz., to fever, tions affecting either the viscera of the thorax, or the mem- short breath, cough, thoracic pains, and expectoration. These brane lining the interior surface of that cavity;" and he adds, symptoms, representing the so-called pneumonia, being of that the symptoms differ but little in these inflammations, nor course, more or less well marked in individual cases, and some one or other of them occasionally absent ; for, as we have seen, do they lead to any difference in cure. Dr. Alison would, himself, seem to admit, that it is impos- the typical case of Cullen’s pneumonia was rarely observed by sible to draw any comparison between the treatment of what Gregory. I need not stop to recount the many different affections which was called pneumonia in former times and what is called pneumonia now. He tells us, that our improved methods of dia- we can nowadays distinctly recognise, during life, as causes of gnosis enable us to ascertain the existence of pneumonia, in those symptoms, in a greater or less well-marked degree. It is enough for my purpose here, to establish the fact, that bleedcases where there is so little of pain, cough, dyspnoea, and fever, that the name of pneumonia would not have been asp- ings were practised indiscriminately, in diseases of a most displied to them in former times. Such cases got well in former similar nature, inasmuch as those diseases, from the nature of, times, under rest, regimen, and shelter. It is evident, there- the parts affected, all presented to the physician a given fore, that before the days ofstethoscopy, only those cases were number of like symptoms. In the number of such diseases we looked upon as inflammation of the lungs in which the symp- may be certain, that there must have been included cases of toms present were urgent and well defined. Great dyspnoea, heart affections, of tubercular disorders, of hepatic diseases, and hard, quick pulse, high fever, rusty sputa, and local pain were of certain other abdominal affections, through whose agency the representatives of the disease to our forefathers. Every the thoracic organs may havebeen secondarily disturbed. Muscular rheumatism of the thoracic parietes, attended with a case of theirs, therefore, must have been what we should call short case-the case Cullen. case-an described breath, pain, and fever, no doubt also was occasionally exquisite by typical But this exquisite case, so described, Dr. Gregory tells us is ranked by Cullen under the head of pneumonia, and treated rare. It was rare then, in Dr. Gregory’s day, and Dr. Alison accordingly, and so also hepatitis. " The situation of the pain," says the very same of it now, it is rare in our day. It was says Dr. Watson, in speakingof hepatitis, "the cough, the benefited by bloodletting in the days of Gregory ; and Dr. short and shallow breathing, used to puzzle the older observers; Alison holds that, in such a case, at the present day, "every and they confess their occasional inability to determine whether other remedy is trifling in comparison with this ;" so that it the inflammation was situated in the lower lobe of the right would be benefited by bloodletting now. lung, or in the liver." Now, I think it must be admitted, that bleedings thus pracHere, then, so far as the comparison holds, it is In favour of complete identity in the disease. The exquisite case was rare, tised, must have been, if not in all, at least in a great nuTuber of and demanded bleeding in former times ; it is equally rare, and cases. verv ill applied. I sav this must be admitted, unless our * MS. Lectures in Library of Med.-Chir. Society, London. equally demands bleeding now. And more than this : Those his
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sham, fever has arisen, that his breathing is short and his pulse rapid, example, peri- that he has cough and pain and expectoration: here is Cullen’s acute fever, difficulty of breath- pneumonia, and for this Cullen would have bled him. Can the breast"-in fact, the symp- one agree in such a case, with Dr. Watson, that it was nothing And are we to believe that bleed- to the purpose " that they might not be certain as to the exact ing in such cases was the proper remedy, equally as in in- seat of the internal inflammation ?" Our diagnosis tells us fla.mmation of the lungs ? Surely pathology justifies us in be- that the short breath, &c., arise from pericardial exudation, lieving something different from this. Suppose the pericarditis perhaps from pleural exudations; and our pathology points out had arisen suddenly and rapidly in the case of aperson affected the nature of the local inflammations which excite them in relawith kidney disease, perhaps in the late stage of the disease. tion to the renal disease. Would not the knowledge of these In such case, the fever may have run high ; and if the pericar- fects have been something to the purpose in the practice of dial effusion was rapid, the heart’s action, and secondarily, the Cullen and the ancients ? Would they not haveworked an freedom of the lungs, may have become suddenly interfered entire revolution in their aaaethod2cs curandi morbos ? with ; then there would have been added to the fever, pain in (To be continued.) the breast, difficulty of breathing, and cough, and not improbably blood-tinged sputa -the symptoms of Cullen’s pneumonia. so-called advances in pathological knowledge
nothing in carditis, might it not produce ing, and more or less pain in toms of Cullen’s pneumonia ? and are to go for
Now I would
the matter.
are a mere
For
"
ask, whether any
ON
" Laudator
Se puero,
censor
temporis acti castigatorque minorum,"
will venture to assert that large bleedings, in such a disease, could havebeen the correct remedy even in the days of Cullen and Gregory ? But can any one doubt that such a case must have again and again fallen into the hands of those physicians, and been subjected to that remedy ? Acute pleurisy and acute pneumonia, also, arising in the course of diseases indicating degeneration and lowered vitality of the system, must have often been treated by them, and,
presenting the symptoms of pneumonia, bled by them.
Could
must have been largely this treatment have been correct in such
THE BY
even
supposing that
THOMAS
BRYANT, ESQ., F.R.C.S.,
ASSISTANT-SURGEON AT
GUY’S
HOSPITAL.
(Concluded from page 442.) Granular degeneration.—The next form of disease to which articular cartilage is liable is one of unusual interest, as it includes the majority of the cases of what is called ulceration of cartilage ; but in these ultimate results may be traced similar changes, so similar indeed as to make us believe that the same process of cell degeneration is the immediate cause of such appearances, and to include all these changes under the one head of granular degeneration. This name is given to distinguish it from another form of degeneration—namely, the fatty, to which cartilage is peculiarly and although in the granular degeneration fat is generally an important ingredient, still it is only secondary in the order of events, and its presence must not therefore induce us to class together cases in which its existence may be called accidental, and those in which it is evident that fat is the
disease has really changed its type ? The tubercular disease of other days must still have been an adynamic disease, indicating defectiveand weakened vital vigour: can we believe that bleeding was ever its right remedy at any moment, from the age of Hippocrates down to our own ? But is it not certain that these large bleedings were frequently practised in tubercular disease, whenever such disease so affected the lungs as to create the symptoms of Cullenian pneumonia, fever, cough, short breath, pain, and sputa? But we do not rest upon conjecture here, for Cullen tells us his practice. " The inflammation of a tubercle of the lung,"he says, " is to be avoided upon the general plan for avoiding inflammation-by bloodletting and by an antiphlogistic diet. This supposes a total abstinence from animal food, and the using of vegetable food almost alone." Gregory also bled in phthisis: "In the beginning it is of very great service," he I says. Now, any one reasoning from the practice of these physicians might argue, in this instance as in the case of Cullen’s pneumonia, that bleeding, in other days, was a proper remedy for tubercular disease, because Cullen and Gregory practised bleeding for that disease. True, it might be said they were ignorant of the pathology of that disease as we understand it now-i. e., that the tubercle was an indication of abnormal and defective nutrition; but still their clear and intelligent minds were not likely to be deceived as to the necessity of the practice in any particular case. They would not have bled so largely unless the nature of the case required the bleeding. Therefore-the argument runs—as they were not in error when they bled, and as we are not in error in abstaining from bleeding now, it is manifest that"disease has changed its type !" I cannot suppose, however, that anyone will really assert that large bleedings were ever requisite in tubercular diseases, in pericardial effusions as mentioned above, or in other adynamic diseases which give rise, primarily or secondarily, to the symptoms of Cullen’s pneumonia. And if it is admitted, as I think it necessarily must be, and for reasons above given, that Cullen and the ancient fathers actually did bleed in these cases, then it follows that these physicians certainly did practise bleeding in many cases where the well-being of the patient would have required an omission of the practice: and therefore I cannot think, with Dr. Watson, that Dr. Bennett’s argument flies wide of its mark. Is it true, as Dr. Watson asserts, " that they"-he is speaking of Cullen and Gregory-" were certainly competent to ascertain, beyond all doubt, that inflammation was going on somewhere within the chest"? What I have said above seems to me clearly to show that they were not so cases,
PATHOLOGY OF ARTICULAR CARTILAGES.
liable ;
primary change.
In this form of diseased cartilage, the investigations of Professor Redfern have left but little for other investigators to discover, and my own researches have but tended to convince me of the truth of his conclusions. Microscopically very similar changes are detected in the cells, and the structure in which they are imbedded. The change commencing in the cells consists first of their enlargement and irregular distribution, instead of their general arrangement in groups and equal size. The cell contents then gradually become granular, and the nuclei become lost, as if split up, or degenerated into simple granules. These granules multiplying distend their mother cell, till at last the wall bursts, and the granules are dispersed into the hyaline tissue. Cavities are thus formed of all sizes, varying from the natural size of healthy cartilage cells to cavities of larger dimensions, till at last the structure is completely altered, but little else than granules being visible on microscopical examination. The hyaline substance, in these changes, generally assumes a more passive action. During the gradual enlargement of the cells, its substance becomes apparently absorbed, offering but little obstacle to the cell changes; this absorption continues, till at last the cell cavities approximating unite and form larger ones, the hyaline substance itself almost entirely disappearing. In other cases a different appearance is to be seen. If this cell degeneration has taken place upon the upper or synovial aspect of the cartilage, the cavities, instead of remaining imbedded in their natural matrix, burst, and discharge their granular contents, tearing, asit were, the hyaline material, and giving itafringed, villous, or fibrous appearance. The fibres assume all sizes and all shapes; but in all the same process of their formation is visible, as their free margin and competent, in a great many cases, as regards the main parti- attached base, evidently composed of the hyaline structure, etilar concerned in the argument,--viz. , the necessity or other- prove quite clearly their origin. wise of the bloodletting. Their diagnosis and their pathology If the degenerative changes occur upon the surface of the told them that the lungs were obstrncted, and that fever was cartilage in contact with the bone, allied appearances are there, but could not have told them the tale which diagnosis visible. In some instances the hyaline substance itself becomes and pathology teach us at this present day. Take the case of granular, this being apparently the change which it generally a patient who had renal disease yesterday ; to-day we find that undergoes in rapid disease.
467
able to a due knowledge of pathological anatomy; and therefore to this source is also due the prevention of secondary ulceration of articular cartilage. This ANTICIPATION of secondary disease through the timely identification and removal of its structural, or internal cause, fulfils the HIGHEST APPLICATION of PATHOLOGICAL ANATOMY to
If, however, pathological anatomy can alone verify internal THERAPEUTICS. But concurrently with ulceration from caries, and more of disease and injury, let us further examine the conseadmission. We shall thus discover more fully rarely from synovitis, we observe more general consequences quences of this The heart beats feebly, or at least irregularly, and the ensue. the intimate relations of that science to therapeutics. For this purpose I would select inflammatory diseases of the pulse is therefore weak and fickle; the respiration becomes joints, which present in themselves ample illustrations of hurried; the organs of digestion soon sympathise, for the apinternal causes and their consequences. petite fails, and diarrhoea ensues; whilst the skin pours forth Observe, then, commencing synovitis -say of the knee-joint. abundantly the night-sweats of hectic fever, and the urine We discover a painful spot, and this spreading gradually over deposits its lithates as the body wastes and the strength de-the whole articulation. Very shortly, a fluid and fluctuating clines. The early detection and removal of either cause in swelling supervenes, the shape of which, although that of the operation prior to suppuration, would assuredly have alike distended synovial capsule, is yet, with its size, also influenced prevented not only adjacent structural disease-ulceration of by the compression of surrounding ligaments and tendons. If cartilage, but also these disturbances of 1’emotefunct’iol1s. In like manner we may not only anticipate the adjacent and now the joint were opened, and the synovial.membrane exposed, we should observe its undue vascularity, of a more or remote consequences of disease, but prevent also destructive less scarlet colour, and that perhaps some blood had actually results in those tissues where the disease originated. We escaped, tinging thereby the serum and lymph also effused must thus distinguish results from consequences. A consewithin the capsule, which with these contents together form quence is that which follows after a previous condition, which the fluctuating and elastic swelling of acute synovitis. At may itself have disappeared. A result is not merely an effect, this early period the synovial membrane still retains its usual but may be considered the final sequent, or termination of one thinness and pliancy. It may, however, happen that pus is and the same condition, itself persistent. If, thus, the prosubsequently poured out within the joint, and, concurrently gress of synovitis be not speedily arrested, that condition will with such an effusion, the cartilages lose their substance, as if almost invariably terminate in chronic thickening and induraulcerated. Here, then, we trace the extension of pus-forming tion of the capsule. Again, if scrofulous caries of the tibia run its course, then the cancellated bone softens and disintegrates; synovitis to disintegration of the neighbouring cartilages. The removal of the primary synovitis would therefore, in the reddish serum within the cancelli is replaced by an albumithis instance, have actually prented disease of an adjoi2lil?g nous, granular, cheesy substance; whilst neighbouring cartilages tissue. This ANTICIPATION of disease, through the early detec- disappear, and the joint collapses. In either case the function tion of an internal cause in operation, is also illustrated by the of the part affected is entirely sacrificed—whether that of the history of scrofulous caries; but its practical application is less synovial membrane, now thickened and inflexible, or that of satisfactory than to synovitis. For the more early structural the articulation itself,—from the permanent and total dischanges of scrofulous caries are less apparent, and their progress organisation of chronic caries. This result-perhaps the irretherefore more insidious. Indeed, we do not at first observe parable loss of function-might certainly have been prevented any well-marked external sign of internal disorganization, and by the early recognition and removal of its structuralcause; are only induced by the equivocal (functional) symptoms of whilst its immediate effect—that of impaired function—may pain and lameness to suspect the destructive process going on also be restored by the timely removal of the structural cause within the bone. Pathology, therefore, does more than with which it is conjoined. For the present, time will not permit me to pursue this pathological anatomy to aid our diagnosis of incipient caries. Yet this assistance is but little. The pain in the head of the enquiry further; but in my next communication I shall present tibia, for instance, may at first be only trifling, perhaps inter- a summary of this paper, and then trace the argument on to mittent, yet fixed ; aggravated also on percussion of the joint, further results. causes
and increasing as the disease progresses. If now the cancellated bone were examined, we might observe its consistence softened, and the cancelli filled with reddish serum; but no further destructive change may as yet have ensued. Weeks, or perhaps months, may pass away before the puffy and elastic swelling of soft tissues around the joint arrests our serious attention. At length, however, the uniform and characteristic shape, no less than the enlargement also of the articulation—rendered even more apparent by the emaciation and semi-flexed position of the limb-together corroborate our diagnosis; perhaps only to be confirmed, when too late, by the friction of the articular surfaces, now denuded of their cartilage, and by undue mobility, or perchance fixed dislocation, of the joint when thus loosened and disorganized. If, then, the conseqxce;2ces of scrofulous caries are so disastrous, its early removal is the more imperative. The destruction of articular cartilage is, indeed, a more frequent conse.quent of this cause than of pus-forming synovitis; but, on reviewing the history of both caries and synovitis, it would appear that inflammation affecting the tissues of joints usually begins peripherally, and proceeds inwards to deeper parts. The primary ulceration of articular cartilage is, in fact, of com. paratively rare occurrence. Weshould therefore be prepared to discover some traces, at least, of previous inflammatory vascularity, in either the synovial membrane or in the cancellated bone, adjoining those cartilages which have been subsequently involved. If, then, the ulceration of articular cartilage is mostly of secondary occurrence to either caries or synovitis, it must be obvious that, by our early detection and removal of either disease when present, we may reasonably hope also to prevent a consequence so fatally destructive of the articulation. Now the carliest unequivocal sign of synovitis and caries is that of swelling, the precise nature of which, like that of other tumours, may be further determined by the examination of its contents, procured by puncture with a grooved needle. Thus the early recognition and interpretation of swelling are refer-
REMARKS ON THE
INFLAMMATION AND BLOODLETTING CONTROVERSY. BY W. O.
MARKHAM, M.D., F.R.C.P.,
PHYSICIAN TO ST.
MARY’S
HOSPITAL.
(Continued from p. 441.) FiRST of all, then, let us consider the nature of the evidence which has been offered in favour of this assumed change in the type of disease. By change in the type of disease is meant, asunderstand it, not a change in the essential nature of the disease itself, but a change in the condition of the body which is the subject of the disease. Pneumonia, for instance, is the same disease now, in so far as its anatomical characters are concerned, as pneumonia ever was, but the body in which the inflammation manifests itself is changed. The general diathesis of human nature has undergone some gradual alteration, so that the reaction of disease upon man is different now from what it was in the good old times, all which is proved by the fact that men did bleed in those times, but that they don’t bleed now; that bleeding was requisite once, but superfluous, and even dangerous, now. This change, moreover, is not a partial one; the entire human race it would appear has probably suffered the novel phasis. Not here only, but at the antipodes likewise, men no longer bear the bleedings they were once
beneficially subjected to.
From this it appears that the fact of an assumed change of type in disease rests mainly upon the circumstance that dis-
465
eases, having the same anatomical characters, receive at the cases of slighter kinds of pneumonia, with ill-marked and not present moment a vastly different method of cure from what urgent symptoms, (whose existence is revealed only through they did in former times; that formerly they presented sthenic the stethoscope,) recovered without bleeding, "just as they characters, but that now inflammation is asthenic. It is worthy may have done of late years under homœopathic treatment, and of remark here, incidentally, that Dr. Watson’s ideas of the often without the aid of stimulants." To such cases, indeed, change of type in disease differ in some respects from those of in former times, the name of pneumonia would not have been Some of them," Dr. Alison says, "am convinced Dr. Alison. Dr. Alison seems to conclude that for 2000 years given. inflammations have required large venesection, and now only were regarded in former times as fevers, of different denominasince the beginning of the present century have no longer the tions, and were treated as idiopathic fevers of the time and These slight pneumonias, it appears, were treated characters w hich demand it. Dr. Watson, on the other hand, place." "is firmly persuaded that there are waves of time through in those days as we treat them now--without bleeding. We which the sthenic and asthenic characters of disease prevail in know them, by stethoscopic signs, to be pneumonia; the succession, and that we are at present living amid one of its ancients knew them not as such, because auscultation was un. "
adynamic phases." This persuasion Dr. Watson derives from own personal experience, and from facts recorded in the history of medicine. Of course, also, it is assumed, as an un-
known. If this be true-that is, if pneumonia was only known in former days by certain urgent symptoms, and if the cases of doubted fact, that the treatment of former times was correct, pneumonia were rare in which these urgent symptoms preand that the treatment of the present time (however opposite) sented themselves-then pneumonia (as we understand the is also correct. term) must have been a disease rarely treated by bloodletting Now one may surely, on the threshold of the subject, be ex- in former times. Paradoxical as this may appear, it seems to cused if one feels sceptical concerning a fact of so extraordinary me to be the only conclusion at which we can arrive, according a kind; and surely no one can be blamed if he demand, before to Dr. Alison’s own showing. The rare and exquisite case of accepting the proposition, some clear and undeniable evidence pneumonia they recognised, and they bled it; the numerous of its correctness. Bleeding-the assertion is-from the time every-day cases of pneumonia, in which no urgent symptoms of Hippocrates down to the days of Cullen and Gregory, has marked the malady, and which only stethoscopy could define, been practised as the true cure for inflammations, and rightly were unrecognised, and were unbled Then as Now. But if this be true, how are we to account for the frequent practised; for upwards of 2000 years diseases have been sthenic. Bleeding, in these latter days, has not been practised, and and large bloodlettings which our forefathers are said to have rightly so; inflammations for, say, thirty years past, have been perpetrated in pneumonia ? The answer, I fancy, is satisfactory asthenic! The astonishing conclusion involved in the propo- enough ; it is to be found in the meaning attached by them to sition might almost justify one in doubting its correctness; and the term pneumonia. This meaning has, I am inclined to think, certainly of the two alternatives, I should think it as easy to not been always sufficiently kept in view by those who have believe that doctors have been for 2000 years bleeding in vain, discussed this subject of Inflammation and its Treatment. as that now for the first time disease has begun to show a Pneumonia, as we have said, meant in Cullen’s mind, inflam. changeful aspect, after having maintained an unaltered type mation of the Inngs, plenritis, bronchitis, endocarditis, peri. for 2000 years. I will now endeavour to show what sort of carditis, and doubtless many other affections of the thoracic evidence this proposition is founded on. organs. Dr. Gregory* says : ’’ There are several different names given A little consideration of the subject will show us, that the only way by which we can hope to arrive at any rational and to the Diseases in the Thorax, as the inflammation attacks difsatisfactory conclusion concerning it, is by a comparison of the ferent viscera, as the pleura, lungs, mediastinum, diaphragm, nature of inflammatory diseases in former days, and the results or pericardium, but all these are so connected that it is difficult of treatment employed for their cure, with similar diseases and to make a proper distinction. The peripneumony sometimes their cures, as observed by ourselves at the present time. Is it happens by itself, but I believe this is never the case with the possible to obtain such a comparison ? I cannot think that it inflammation of the other four viscera ; and, besides, from the is. Our knowledge of the pathology of diseases and our dia- symptoms, it is almost impossible to say what part is affected. gnosis have undergone a complete revolution; and, oddly The treatment is pretty much the same in all. On this account enough, it is well to remark, the revolution seems to have I shall consider them altogether, and if anything particular occurred at a somewhat similar moment to that in which the occurs to any one, mention it separately." From all this, it appears clear, that the diseased conditions reputed change of type in disease was effected. The knowledge which we possess of the nature and progress of internal inflam- for which these large bleedings are said to have been practised, mations-all must admit-is vastly superior to, and different and which were comprised by Cullen under the generic term from, that which our forefathers possessed. When Cullen Pneumonia, included all those affections, of whatsoever nature, speaks of pneumonia, he means, "the whole of the inflamma- which give rise to certain special symptoms-viz., to fever, tions affecting either the viscera of the thorax, or the mem- short breath, cough, thoracic pains, and expectoration. These brane lining the interior surface of that cavity;" and he adds, symptoms, representing the so-called pneumonia, being of that the symptoms differ but little in these inflammations, nor course, more or less well marked in individual cases, and some one or other of them occasionally absent ; for, as we have seen, do they lead to any difference in cure. Dr. Alison would, himself, seem to admit, that it is impos- the typical case of Cullen’s pneumonia was rarely observed by sible to draw any comparison between the treatment of what Gregory. I need not stop to recount the many different affections which was called pneumonia in former times and what is called pneumonia now. He tells us, that our improved methods of dia- we can nowadays distinctly recognise, during life, as causes of gnosis enable us to ascertain the existence of pneumonia, in those symptoms, in a greater or less well-marked degree. It is enough for my purpose here, to establish the fact, that bleedcases where there is so little of pain, cough, dyspnoea, and fever, that the name of pneumonia would not have been asp- ings were practised indiscriminately, in diseases of a most displied to them in former times. Such cases got well in former similar nature, inasmuch as those diseases, from the nature of, times, under rest, regimen, and shelter. It is evident, there- the parts affected, all presented to the physician a given fore, that before the days ofstethoscopy, only those cases were number of like symptoms. In the number of such diseases we looked upon as inflammation of the lungs in which the symp- may be certain, that there must have been included cases of toms present were urgent and well defined. Great dyspnoea, heart affections, of tubercular disorders, of hepatic diseases, and hard, quick pulse, high fever, rusty sputa, and local pain were of certain other abdominal affections, through whose agency the representatives of the disease to our forefathers. Every the thoracic organs may havebeen secondarily disturbed. Muscular rheumatism of the thoracic parietes, attended with a case of theirs, therefore, must have been what we should call short case-the case Cullen. case-an described breath, pain, and fever, no doubt also was occasionally exquisite by typical But this exquisite case, so described, Dr. Gregory tells us is ranked by Cullen under the head of pneumonia, and treated rare. It was rare then, in Dr. Gregory’s day, and Dr. Alison accordingly, and so also hepatitis. " The situation of the pain," says the very same of it now, it is rare in our day. It was says Dr. Watson, in speakingof hepatitis, "the cough, the benefited by bloodletting in the days of Gregory ; and Dr. short and shallow breathing, used to puzzle the older observers; Alison holds that, in such a case, at the present day, "every and they confess their occasional inability to determine whether other remedy is trifling in comparison with this ;" so that it the inflammation was situated in the lower lobe of the right would be benefited by bloodletting now. lung, or in the liver." Now, I think it must be admitted, that bleedings thus pracHere, then, so far as the comparison holds, it is In favour of complete identity in the disease. The exquisite case was rare, tised, must have been, if not in all, at least in a great nuTuber of and demanded bleeding in former times ; it is equally rare, and cases. verv ill applied. I sav this must be admitted, unless our * MS. Lectures in Library of Med.-Chir. Society, London. equally demands bleeding now. And more than this : Those his
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sham, fever has arisen, that his breathing is short and his pulse rapid, example, peri- that he has cough and pain and expectoration: here is Cullen’s acute fever, difficulty of breath- pneumonia, and for this Cullen would have bled him. Can the breast"-in fact, the symp- one agree in such a case, with Dr. Watson, that it was nothing And are we to believe that bleed- to the purpose " that they might not be certain as to the exact ing in such cases was the proper remedy, equally as in in- seat of the internal inflammation ?" Our diagnosis tells us fla.mmation of the lungs ? Surely pathology justifies us in be- that the short breath, &c., arise from pericardial exudation, lieving something different from this. Suppose the pericarditis perhaps from pleural exudations; and our pathology points out had arisen suddenly and rapidly in the case of aperson affected the nature of the local inflammations which excite them in relawith kidney disease, perhaps in the late stage of the disease. tion to the renal disease. Would not the knowledge of these In such case, the fever may have run high ; and if the pericar- fects have been something to the purpose in the practice of dial effusion was rapid, the heart’s action, and secondarily, the Cullen and the ancients ? Would they not haveworked an freedom of the lungs, may have become suddenly interfered entire revolution in their aaaethod2cs curandi morbos ? with ; then there would have been added to the fever, pain in (To be continued.) the breast, difficulty of breathing, and cough, and not improbably blood-tinged sputa -the symptoms of Cullen’s pneumonia. so-called advances in pathological knowledge
nothing in carditis, might it not produce ing, and more or less pain in toms of Cullen’s pneumonia ? and are to go for
Now I would
the matter.
are a mere
For
"
ask, whether any
ON
" Laudator
Se puero,
censor
temporis acti castigatorque minorum,"
will venture to assert that large bleedings, in such a disease, could havebeen the correct remedy even in the days of Cullen and Gregory ? But can any one doubt that such a case must have again and again fallen into the hands of those physicians, and been subjected to that remedy ? Acute pleurisy and acute pneumonia, also, arising in the course of diseases indicating degeneration and lowered vitality of the system, must have often been treated by them, and,
presenting the symptoms of pneumonia, bled by them.
Could
must have been largely this treatment have been correct in such
THE BY
even
supposing that
THOMAS
BRYANT, ESQ., F.R.C.S.,
ASSISTANT-SURGEON AT
GUY’S
HOSPITAL.
(Concluded from page 442.) Granular degeneration.—The next form of disease to which articular cartilage is liable is one of unusual interest, as it includes the majority of the cases of what is called ulceration of cartilage ; but in these ultimate results may be traced similar changes, so similar indeed as to make us believe that the same process of cell degeneration is the immediate cause of such appearances, and to include all these changes under the one head of granular degeneration. This name is given to distinguish it from another form of degeneration—namely, the fatty, to which cartilage is peculiarly and although in the granular degeneration fat is generally an important ingredient, still it is only secondary in the order of events, and its presence must not therefore induce us to class together cases in which its existence may be called accidental, and those in which it is evident that fat is the
disease has really changed its type ? The tubercular disease of other days must still have been an adynamic disease, indicating defectiveand weakened vital vigour: can we believe that bleeding was ever its right remedy at any moment, from the age of Hippocrates down to our own ? But is it not certain that these large bleedings were frequently practised in tubercular disease, whenever such disease so affected the lungs as to create the symptoms of Cullenian pneumonia, fever, cough, short breath, pain, and sputa? But we do not rest upon conjecture here, for Cullen tells us his practice. " The inflammation of a tubercle of the lung,"he says, " is to be avoided upon the general plan for avoiding inflammation-by bloodletting and by an antiphlogistic diet. This supposes a total abstinence from animal food, and the using of vegetable food almost alone." Gregory also bled in phthisis: "In the beginning it is of very great service," he I says. Now, any one reasoning from the practice of these physicians might argue, in this instance as in the case of Cullen’s pneumonia, that bleeding, in other days, was a proper remedy for tubercular disease, because Cullen and Gregory practised bleeding for that disease. True, it might be said they were ignorant of the pathology of that disease as we understand it now-i. e., that the tubercle was an indication of abnormal and defective nutrition; but still their clear and intelligent minds were not likely to be deceived as to the necessity of the practice in any particular case. They would not have bled so largely unless the nature of the case required the bleeding. Therefore-the argument runs—as they were not in error when they bled, and as we are not in error in abstaining from bleeding now, it is manifest that"disease has changed its type !" I cannot suppose, however, that anyone will really assert that large bleedings were ever requisite in tubercular diseases, in pericardial effusions as mentioned above, or in other adynamic diseases which give rise, primarily or secondarily, to the symptoms of Cullen’s pneumonia. And if it is admitted, as I think it necessarily must be, and for reasons above given, that Cullen and the ancient fathers actually did bleed in these cases, then it follows that these physicians certainly did practise bleeding in many cases where the well-being of the patient would have required an omission of the practice: and therefore I cannot think, with Dr. Watson, that Dr. Bennett’s argument flies wide of its mark. Is it true, as Dr. Watson asserts, " that they"-he is speaking of Cullen and Gregory-" were certainly competent to ascertain, beyond all doubt, that inflammation was going on somewhere within the chest"? What I have said above seems to me clearly to show that they were not so cases,
PATHOLOGY OF ARTICULAR CARTILAGES.
liable ;
primary change.
In this form of diseased cartilage, the investigations of Professor Redfern have left but little for other investigators to discover, and my own researches have but tended to convince me of the truth of his conclusions. Microscopically very similar changes are detected in the cells, and the structure in which they are imbedded. The change commencing in the cells consists first of their enlargement and irregular distribution, instead of their general arrangement in groups and equal size. The cell contents then gradually become granular, and the nuclei become lost, as if split up, or degenerated into simple granules. These granules multiplying distend their mother cell, till at last the wall bursts, and the granules are dispersed into the hyaline tissue. Cavities are thus formed of all sizes, varying from the natural size of healthy cartilage cells to cavities of larger dimensions, till at last the structure is completely altered, but little else than granules being visible on microscopical examination. The hyaline substance, in these changes, generally assumes a more passive action. During the gradual enlargement of the cells, its substance becomes apparently absorbed, offering but little obstacle to the cell changes; this absorption continues, till at last the cell cavities approximating unite and form larger ones, the hyaline substance itself almost entirely disappearing. In other cases a different appearance is to be seen. If this cell degeneration has taken place upon the upper or synovial aspect of the cartilage, the cavities, instead of remaining imbedded in their natural matrix, burst, and discharge their granular contents, tearing, asit were, the hyaline material, and giving itafringed, villous, or fibrous appearance. The fibres assume all sizes and all shapes; but in all the same process of their formation is visible, as their free margin and competent, in a great many cases, as regards the main parti- attached base, evidently composed of the hyaline structure, etilar concerned in the argument,--viz. , the necessity or other- prove quite clearly their origin. wise of the bloodletting. Their diagnosis and their pathology If the degenerative changes occur upon the surface of the told them that the lungs were obstrncted, and that fever was cartilage in contact with the bone, allied appearances are there, but could not have told them the tale which diagnosis visible. In some instances the hyaline substance itself becomes and pathology teach us at this present day. Take the case of granular, this being apparently the change which it generally a patient who had renal disease yesterday ; to-day we find that undergoes in rapid disease.
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