The morbid appearances are as follows: Enlarged burso, sometimes multilocular; many pendulous excrescences in the interior, like the appendicæ epiploice of the large intestine, and small processes like melon seeds, foreign bodies, or loose cartilages. In the first stage the articulating fibro-cartilages are of a dull-yellow color, softened so as to be easily penetrated by a probe, thinned and separated into fibres, in fact, in an early state of disintegration. The semilunar cartilages are generally removed altogether as the ultimate result of this disease, but rarely found hypertrophied. The cartilage of incrustation becomes removed; the patella is seen broader than natural; the internal articular surface of the tibia is usually narrower than the external, which last is found to present a large circular outline, partially surrounded by a rim of bone, and elsewhere having a smooth and eburnated surface; bony vegetations are seen on the posterior and lateral margins of the condyles of the femur; the most common luxation in this variety is the sub-luxation of the femur inwards.

We have now given a very slight sketch of the manner in which the affection of two of the chief articulations in the body are treated, but in the work itself will be found every information which can be desired concerning the diagnosis, morbid appearances, &c., of the affection, not only when it attacks the hip and knee, but as seen when all the important joints liable to become altered by this disease are implicated, as the shoulder, elbow, wrist, and the joints of the carpus, metacarpus, and phalanges; also of the ankle and the joints of the tarsus, metatarsus, and toes; the temporo-maxillary, sterno-clavicular, and anomio-clavicular articulations; and, lastly, the disease as it affects the vertebral column.

The consideration of the treatment of the disease, though contained in the first part of the book, we have left for consideration till the last; only twelve pages are given to the subject, and these contain more the opinions of others than the results of the author's own experience.

Dr. Adams first reviews the question as to whether the disease is of an inflammatory nature or not, as this question should be answered before the treatment can be advantageously discussed. He first quotes the late Dr. Colles, where he states that, "He did not think that genuine inflammation had any thing to do with its origin, for nothing like pus or lymph had ever been found in the affected joints; if it be inflammatory, it has not the characters or consequences of true inflammatory action."

Dr. Todd's opinion is next given, who thinks the "affection of the joints may be most correctly described as an abnormal nutrition, occasioned by the presence of a peculiar matter in the nutrient fluid, affording doubtless certain points of resemblance to chronic inflammation, yet differing from it in a very marked manner."

Other quotations are given from authors holding opposite opinions, especially Cruveilhier and Sir B. Brodie, with whom the author evidently coincides, considering that the ordinary causes of the disease, also the pain, swelling, heat, and redness when the affection is external, and the redness of the synovial membrane and fimbria, and the inordinate effusion of synovial fluid, as well as the hyperamic condition of the bones themselves, all point to inflammatory action.

The contents of the three or four pages in which Dr. Adams really discusses the treatment of the disease, may be thus summed up. During the earlier periods, the application of leeches and cupping-glasses is attended with advantage.

In a few instances, the combination of guaiacum and sulphur, &c., called the Chelsea pensioner's electuary, has proved beneficial after its long-continued use; so also the ammoniated tincture of guaiacum. Anodynes should be employed in the form found to produce least uneasiness to the patient. As to the question whether those afflicted with this disease should yield to their disorder, and condemn themselves, as it were, to immobility for life, or whether they should contend against it, and persevere in walking, even although it proved painful and fatiguing, Dr. Anams replies as follows: "That in the commencement of the disease, rest, cupping, the frequent use of leeches, con

finement to a warm atmosphere, warm baths, and mercurials combined with opium, seem to be the most rational means to resort to, with the expectation of arresting the progress of the affection in its early stages; but, on the contrary, if chronic rheumatic arthritis has gone on to the destruction of the articular surfaces, and the movement of the joint is followed rather by a stiffness of the limb than actual pain-in this case, some walking exercise daily may not only be permitted, but recommended to the patient: his general health will be thereby improved, and the articular surfaces will be found to move more freely on each other, owing most probably to the eburnation of them which we know to be induced by motion. If, however, on the one hand, it be true, that in the early stages of the disease exercise is likely to aggravate the symptoms; still, upon the other, it is important to have present to our minds the evils which result from the system of the articulations being kept for a great length of time in a state of quietude; for my experience accords with that of Teissier and Bonnet, that prolonged and absolute repose of the joints, particularly in old persons, is calculated to determine serious alterations in the articular structures, such as effusion of a sero-sanguineous fluid into the synovial sacs, the formation of false membranes, erosion and thinning of the cartilages, &c." With regard to the efficacy of different mineral waters in this affection, Dr. Adams thinks at present the treatment of the disease has not been sufficiently advanced to enable us to determine as to the positive and relative merits of the different watering-places; but he thinks, and in this we most fully coincide, that "when the affection has become more generally understood and distinguished from gout and rheumatism properly so called, and the results of experience faithfully recorded, then, and not till then, will the physician be enabled to speak more positively as to the general medical treatment both of the local and constitutional forms of chronic rheumatic arthritis."

In concluding our notice of Dr. Adams' work, we can heartily recommend it to the perusal of our readers, feeling confident that it is one which represents the results of much labor and perseverance in the study of a most obscure affection; and if we may feel at first somewhat disappointed at finding so little space devoted to the pathology of the disease and its treatment, yet on further consideration we shall perceive that this paucity is in no way the fault of our author, but depends rather on the imperfect state of knowledge on the subject. The work throughout is copiously illustrated by numerous woodcuts, and the atlas contains many valuable illustrations of the changes induced by the disease.

On Purpura and its Connection with Splenic Disease. By Dr. HABERSHON, ASsistant-Physician to Guy's Hospital. ("Guy's Hospital Reports," Third Series, vol. iii. 1857.)

Dr. Habershon divides purpura into—

1, 2. The simple and hemorrhagic forms, arising from disease of the spleen. and liver.

3. The purpura erythematica and urticans, the result of acute hyperæmic conditions of the skin, and more allied to the exanthems.

4. The congestive variety, as found in disease of the heart, from extreme con gestion of the capillaries. In this variety the blood, in all probability, is modified by the engorged viscera, and, in advanced life, the capillaries themselves may be degenerated.

5. The petechial form in typhus and typhoid fever.

The paper is illustrated by fourteen cases, and all the ordinary points in connection with the disorder are carefully considered. Attention was drawn to the spleen by the two following cases :—

CASE 4.-William G, æt. 34, a rope-maker, residing in the old Kent road, admitted under my care June 1st, 1854. He stated that he had never been ill, and that he felt well till three days before admission, when purpurous spots made their appearance on his ankles, but afterwards became general. They were not preceded by any particular symptoms. He was a married man, and his habits of life had been regular and temperate; his diet had been a mixed

one, beef and mutton, and he had not restricted himself in the use of vegetables. The gums became very sore and tender, and began to bleed, but epistaxis did not come on for several days. The bowels were regularly acted upon. On admission there were numerous spots of purpura on the body; the motions were dark and extremely fetid; the urine contained neither blood nor albumen. The gums were slightly spongy and bleeding. The pulse small and feeble. The pupils rather dilated. Sulphate of magnesia, dilute sulphuric acid, and infusion of roses, were given every four hours; meat diet, and greens. June 3d, the epistaxis had ceased, but the gums continued to bleed. On examining the blood microscopically, there was no increase of the number of white corpuscles; the red were crenate probably from saliva. 4th. Decoction of bark with chlorate of potash were given. 5th. The epistaxis returned. 6th. There was pain in the left hypochondrium; no relief to other symptoms. Ordered: Tincture of iron, mxv, with lemon-juice, 3j, every four hours. 8th. He was much worse, the hemorrhage from the nose and mouth had increased. He was insensible and comatose. The pulse was slow, small, and feeble. He had passed a considerable quantity of blood from the rectum and from the bladder. The pupil of the left eye was much dilated, the right much contracted, the eyelid only partially closed. The right side was hemiplegic, with loss of motion and sensation, and the temperature was lower than the other; tickling the left foot produced excito-motory movement, not so the right. The paralysis had come on the same morning at ten, and was preceded by severe pain in the head. The coma continued till death, on the afternoon of the same day, and death appeared to be immediately caused by the passage of the blood into the larynx, and the obstruction about the epiglottis.

Inspection was made twenty-one hours after death. On the right conjunctiva there was ecchymosis, and the left side of the mouth was fallen. The whole of the body was thickly studded with spots of purpura, there was blood on the gums and at the nostrils. Head: There were spots of ecchymosis on the scalp, and the dura mater was thickly studded with points of effused blood. The arachnoid was dry, and the convolutions much compressed. Blood was effused into the meshes of the pia mater; and on the left side corresponded to the temporal bone. The fluid in the ventricles was slightly tinged with blood, more so on the left than on the right side. The left posterior cornu contained blood, and between this portion of the ventricle and the external surface was an irregular clot of blood, and numerous points of ecchymosis; the surrounding brain substance was soft and diffluent. Chest: The mucous membrane of the oesophagus, as high as the clavicle, was infiltrated with blood. The trachea presented points of ecchymosis, so also the bronchi. The lungs did not collapse, they were congested, and contained spots resembling pulmonary apoplexy. The pleura had in it a small quantity of bloody serum, and the costal pleura was spotted with bloody points; there was a small quantity of bloody serum in the pericardium; the heart had numerous points of ecchymosis on the anterior surface of the right and the posterior surface of the left ventricle. The heart was flaccid, but its muscular fibre and valves were healthy; its cavities contained fluid blood; its weight nine ounces. Abdomen: In the rectus abdominis there was some blood effused. The peritoneum was healthy; but portions of both small and large intestine were distended with dark-colored bloody fluid. The mucous membrane of the stomach, duodenum, jejunum, and ileum, were throughout ecchymosed. The cæcum was in a similar condition; and blood was poured out into the substance of the mesentery. The liver was pale but healthy in form and structure, three pounds three ounces in weight. The spleen was pale, soft, of a dull red color, and contained very numerous light-colored masses, about the size of peas, through the whole of its substance. These peashaped masses, on microscopical examination, were found to be connected with the splenic capillaries, a larger capillary vessel being observed to be connected with one side of the mass; and on the other were several smaller vessels, but it could not be ascertained whether these ramified over or passed through the structure. The rounded mass consisted of granules and cells; several of them were irregularly aggregated together, so as to constitute the pea shaped mass before mentioned; splenic cells were observed of various sizes generally about

the size of white corpuscles of the blood, some contained a distinct nucleus, others granular matter. The supra-renal capsules were large and pale; the lumbar and other glands healthy, but the areolar tissue about the lumbar nerves was spotted with blood. The kidneys were enlarged, being eleven ounces in weight; the secreting portion was healthy, but a considerable quantity of blood was effused into the mucous membrane of the calyces and the pelvis of the kidney. The bladder contained bloody urine, and its mucous membrane was ecchymosed.

CASE 5.-Joseph O, at 23, was admitted under my care into Guy's, June 28th, 1855, and died on the 30th. He was pale and anæmiated, a man of dissolute habits, who had employed himself as a news-agent, and had resided in Kent Street, Borough. For three months he had had epistaxis, and for about one week before admission he had had a boil on the sacrum, from which a discharge of thin serum took place in considerable quantity. On the day of admission he had discharge of blood from the nose, and from the margins of the gums; the pulse was sharp and jerking, the voice hoarse, the respiration accompanied with a loud stridulous noise; at the base of the right lung there were mucous râles; the conjunctiva was watery, and the urine albuminous. Steel and quinine were administered. On the 30th, the brain became oppressed, and the patient gradually became comatose; a blister was applied to the neck, and a turpentine enema administered. In a few hours death took place.

Inspection. The body was pale, but there was no oedema. Brain: The subarachnoid fluid was increased; at the lower surface of the right lobe of the cerebellum there was a patch of ecchymosis; and the section showed that minute points of blood were extravasated throughout the convolutions in the course of the pia mater, covering a space about an inch in diameter, there were also some points of ecchymosis in the white substance. In the mouth were clots of blood. The larynx contained bloody mucus, but was not oedematous. There was a small quantity of bloody serum in each pleura. The bronchi were full of tenacious mucus. The lungs were very oedematous, slightly compressed, and readily lacerable. Heart: In the right cavities, was firm decolorized clot, in the left small loose clots; there was considerable fatty degeneration of the muscular fibre of the heart, as shown in the wavy mottling of the inner aspect, and on microscopical examination; the left ventricle was dilated and hypertrophied, the weight of the heart fifteen ounces. The stomach and intestines were healthy. The liver was healthy; the gall-bladder full; the spleen four and a half ounces in weight, but the Malpighian bodies were large, pale, and appeared to form a considerable portion of the gland, &c. The kidneys were pale, granular, extremely degenerated; the tubes wasted and full of granules.

Commenting upon these cases, Dr. Habershon says:

"It is to the spleen that attention was drawn in both the cases here recorded, as the only structure presenting evidence of disease which could not be looked upon as the effect rather than the cause. Dr. Copland describes the spleen as sometimes enlarged and softened, but here the appearance was remarkable; the enlarged gland was of a dull red color, and studded throughout with pale yellow spots, from one to three lines in diameter; they were connected with the capillary circulation, and consisted of cells, nuclei and granules. It is doubtless correct to consider them Malpighian corpuscles; and, as far as these observations point, they tend to show that this diseased condition of the spleen is a cause of purpura hæmorrhagica. The researches of Mr. Gray on the 'Structure of the Spleen,' and those of Dr. Hughes Bennett on the Connection of the Spleen with Leucocythemia,' also confirm the connection of this part of the gland-structures with the formative changes of the blood. In the case under my own care the white corpuscles of the blood were not in excess, perhaps the reverse; the disease observed in the spleen may have been the cause of imperfect elaboration of the fibrinous element of the blood. In several fatal cases recorded by Plumbe, the spleen is stated to have been healthy, but they were associated with other fatal diseases, as smallpox, tubercular disease, chronic pneumonia, and diphtheritic inflammation of the mouth. In a case of fatal apoplexy in a child, recently under Dr. Gull's care, with disease of the

aortic valves, aneurism, &c., the spleen presented a similar appearance; it is doubtful whether this state of the spleen had any connection with the fatal effusion of blood, or whether it was merely a condition of functional activity.

"The occurrence of purpura with ague, and the tendency to hemorrhage in that disease, strengthen the idea of a splenic origin of the complaint. So also its occasional presence with disease of the kidney does not militate againt this idea, for in a case (No. 5) under my care, of advanced degeneration of the kidney, in which hemorrhage took place from the gums, &c., the spleen was found in a similar condition. Some forms of purpura, however, should rather be considered as simply of a congestive character; thus, in disease of the heart, whilst the liver and spleen are both engorged, and the healthy function interfered with, we find mechanical obstruction leading to great venous engorgement; the minute capillaries become over-distended and at last ruptured, so that spots of purpura, and even blebs filled with serum and blood, are occasionally the result. Small spots of purpura are frequently associated with cirrhosis; and it is doubtful whether this is not the result of the hepatic disease alone, or whether of associate splenic disturbance; probably the former. In cirrhosis, epistaxis is a not unfrequent symptom; and in this disease, as in simple jaundice, it is very unwise to apply leeches or cupping-glasses without extreme caution, for the difficulty of stopping the bleeding is notorious, and has sometimes nearly led to a fatal termination."

Cases of Idiopathic Fatty Degeneration, with Remarks on Arcus Senilis. By Dr. SAMUEL WILKS, Assistant Physician to Guy's Hospital. ("Guy's Hospital Reports," Third Series, vol. iii., 1857.)

The cases of idiopathic fatty degeneration to which reference is here made, are cases which have not been preceded by any manifest primary disorder or by intemperance, and they are not to be referred to the head of senile fatty degeneration. Their only appreciable and probable causes were hemorrhage, diarrhoea, or miasmata; and the simple question is whether these or similar influences may have produced a debility of the system, of which this general change of all the tissues is the result. Dr. Wilks relates nine cases as examples of this state of fatal anæmia and fatty degeneration. In these cases the subjects are comparatively young, the heart is the organ in which the diseased change is most marked, and the body generally is neither fat nor wasted. The first three of these cases will serve as examples of the rest.

CASE.-Mary B, æt. 31, was admitted under Dr. Hughes, in March, 1855. She had been living as servant at Rotherhithe, and since her marriage, about a year before, had had much domestic trouble. During the whole of this latter period her health had been failing, and, gaining no relief, she came to the hospital. She was then in an extreme state of anæmia, so that a loss of blood at once suggested itself as the cause; but she denied having had any hemorrhage, diarrhoea, or any other symptoms excepting those dependent upon her gradually increasing debility. The catamenia were also regular. Her pallor was so great that it at once arrested the attention of every visitor to the ward. There was no increase of white globules in the blood. She grew feebler and feebler until her death, a fortnight after admission. During this time she had frequent vomiting and diarrhoea. The pulse was quick, and an anæmic cardiac murmur existed. It was afterwards learned that her mind at one time had been affected. The post-mortem examination showed the body spare, but not wasted. The brain was healthy, but having a few small spots of ecchymosis in parts, and the base of the skull was very thin in parts. The heart presented an extreme degree of fatty degeneration. The mitral columns, especially, had about half of their substance occupied by the usual transverse lines of fatty matter. There was no coagulum in the heart or vessels, only a little watery blood escaping from them when cut. They presented no excess of white corpuscles. There was a considerable layer of fat in the integument of abdomen, and also in mesentery, omentum, &c. The liver was very fatty, although not in an extreme degree, for, on microscopic examination, it was seen that the circumference only of the lobules had undergone this change, and not the whole tissue. Kid