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A Treatise on Rheumatic Gout, or Chronic Rheumatic Arthritis of all the Joints. By ROBERT ADAMS, M. D., A. M., M. R. S. A., &c. ; 8vo. pp. 362. Illustrated by wood-cuts and a 4to. atlas of plates. (London: Churchill, 1857.)

This treatise, as stated in the preface, embodies the substance of the Clinical Lectures on this disease, delivered by the author during several years, and comprises also the principal part of many communications made by him from time to time, and already published; hence, therefore, although the work contains views with reference to this disease which have, perhaps, some claim to originality, still it cannot be expected that it will be found to suggest much which can now be considered new, or which had not, either by himself or others, been already laid before the profession. Interspersed throughout the pages are numerous wood-cuts; and an atlas of drawings taken from remarkable specimens of this disease in the Museum of the Richmond Hospital, Dublin, is associated with the work.

On the cover of the work the title "Rheumatic Gout" is applied, within, the first title is "Chronic Rheumatic Arthritis, or Rheumatic Gout;" and the designations given to the disease first demand our notice. The author states that when the wrists, hands and feet are affected the disease is often denominated "rheumatic gout," but when the shoulder, elbow, or knee, singly, or simultaneously, it has been generally named "chronic rheumatism." By Dr. Haygarth, of Bath, the affection was considered to differ both from gout and rheumatism, and called by him "nodosity of the joints." Dr. Haygarth added that by giving the disease a distinct name he trusted it might be considered as a separate genus, and become a more special object of medical inquiry. Cruveilhier calls especial attention to the disease, and proposes to have it named "Usures des Cartilages Articulaires." Dr. Adams agrees with Haygarth and Cruveilhier in thinking it a matter of much importance to give this disease some special designation, so that it may get a distinct consideration from the profession and the public, and proposed, some time since, the term "Chronic Rheumatic Arthritis," the disease being slow in its progress, and of a sub-inflammatory nature, and the joints large and small are the principal seats of it.

We consider the author's term of "Chronic Rheumatic Arthritis" very preferable to that of rheumatic gout, which latter we protest against, for, as we shall find, it has no connection with true gout, and the structural alterations of the joints are no way similar to the changes which occur in the latter disease, and which are peculiar to, and pathognomonic of it; and again the condition of blood is by no means allied to that which occurs in gout.

The 2d chapter is devoted to the consideration of the causes and symptoms of the disease.

It is sometimes a constitutional, sometimes a local disorder; when constitutional it affects numerous joints, and is symmetrical on the two sides of the body. Sometimes when constitutional it seems to have its origin in true rheu matic fever, or acute rheumatism; sometimes, on the other hand, although the patient may be exposed to the ordinary causes, as from the sudden exposure to cold when the body was much overheated by hard labor, it seems to arise gradually without any preceding acute attack; sometimes, again, when confined to one articulation, it appears to be produced by local causes, as the habitual over-exertion or sprain of the joint.

The principal symptoms may be thus enumerated. Some pain, especially at nights, but not so much as might be expected from the amount of anatomical change, rigidity of the joints, and a crackling sensation produced in exercise, accompanied with pain, more especially felt when the patient commences to move about after a period of repose, as after the repose of the night, the muscles are not organically affected, but often the seat of painful spasms, the joints enlarge. The swelling is at first soft and fluctuating, but gradually becomes harder and harder. According to our author, it is found in both sexes and at almost every age; in males the hip-joint, in females the wrists and hands are the parts more frequently affected. With regard to the crackling noise, it is often both felt and heard, not only by the patient, but some

times by others in remote parts of the room. As to the condition of life in which it is most commonly found there exists some discrepancy of opinion; Dr. Adams regards it as occurring chiefly among the laboring poor; Sir B. Brodie, on the other hand, among the upper classes; a difference of opinion possibly explained by a difference in the classes of patients which more prominently came under each surgeon's notice, perhaps occasionally from different diseases being described.

The enlargement of the joint depends on many causes, such as synovial effusion, the exostotic growths, and the distended synovial bursæ, some of which are offsets from the joint, others distinct therefrom; the bursæ of the olecranon are often affected, but no gouty matter is found in them, neither is there any layer of urate of soda seen in or upon the articular cartilage of those cases which the author considers true chronic rheumatic arthritis. During the whole course of his numerous researches, Dr. Adams only once met with true bony anchylosis, and suppuration is exceedingly rare.

Chapter III. includes the diagnosis and prognosis of the disease. Haygarth, the earliest writer on the subject, states as follows: "The nodes appear most nearly to resemble gout, both of them are attended with pain and swelling of the joints, but they differ essentially in many distinguishable circumstances. In gout, the skin and other integuments are generally inflamed, with pain, which is very acute, soreness to the touch, redness and swelling of the soft parts, but in no respect like the hardness of bone. The gout attacks the patient in paroxysms of a few days, weeks, or months, and has complete intermissions, at first for years, but afterwards for shorter periods. The gout attacks men much more frequently than women. There is one distressful circumstance which distinguishes this disease; it has no intermission and but slight remissions, for during the remainder of the patient's life, the nodes gradually enlarge, impeding more and more the motion of the limb; the malady spreads to other joints without leaving or producing any alleviation in those which had been previously attacked."

As to prognosis, it is less serious when local than when general, in which latter case gradual progression from bad to worse seems inevitable. The prognosis, however, as far as life is concerned, is not serious provided the patient be in easy circumstances.

In Chapter IV. the anatomical characters of the disease are given.

1. Alterations in the fibro-synovial structures of the joints produced by the disease; capsules distended with synovial fluid, thickened, and exhibiting signs of chronic inflammation. The redundant fluid is afterwards absorbed, and the capsular membrane acquires a preternatural density (in the hip-joint it has been seen a quarter of an inch thick), sometimes it even contains bone in joints long affected; in the interior many of the structures become altogether removed, as the round ligaments in the hip-joint, the tendon of the biceps in shoulder. All the articulations which have been long affected are usually divested of their cartilage of incrustation. In ancient cases the interarticular fibro-cartilages are also absorbed, as in the lower jaw, wrist, and knee-joint. In consequence of the distension produced in the capsular membrane by the increased quantity of fluid in the first stage, the lateral ligaments of the ginglymoid joints become preternaturally elongated, from the effects of which they are slow to recover; hence, at first, the laxity of these parts in the smaller joints gives them at first a greater degree of mobility, rendering partial or complete dislocation more easy than natural; the capsular ligaments of the other joints also retain their elongated state favoring a similar dislocation in them.

Foreign bodies, varying in number, size, and consistence, either bony or cartilaginous, connected more or less closely by slender or broad-based ligaments to the other structures of the joints, and sometimes even free, are not of uncommon occurrence; and when a joint has been long and severely affected, "additamentary-bones" (so called by our author), have been found deepening and enlarging the cavities of reception for the heads and condyles of bones composing the articulations; and lastly, in such joints membranous produc"vascular excrescences" are often met with.

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Alterations in the osseous system.-The cartilaginous incrustations, as before said, are completely removed; and when the disease is of long standing, its place is supplied by an ivory-like enamel, remarkable for its polish and hardness. In the first class joints, such as the hip and shoulder, the surface of the head of the bone becomes like an ivory ball; in the ginglymoid joints, at the knee, &c., the cartilage is supplied by patches of this same substance (ivory eburnations), marked by grooves hollowed out in the direction of the movements of the joints. The denuded surfaces become partly worn away, and a smooth enamel is formed by the mutual action of the bones on each other; and, around the articular surfaces thus mechanically acted upon, bony vegetations arise. The heads of the bones thus flattened have the appearance as if they had been crushed down, and in the hip and shoulder-joints may lead to error of diagnosis. The sockets of the bones are also altered, in some cases rendered much deeper, in others shallower and otherwise deformed, and the shafts of the bones, especially in the vicinity of diseased joints, become dense and hypertrophied.

In Part II, the special affections of each joint are detailed, and by far the greatest portion of the book is devoted to their consideration. We will give one or two illustrations.

Hip joint. The causes of the affection of this joint are of the same nature as in the rest, but perhaps blows and falls are more frequently operative; when it appears, as it often does, as a local complaint, it rarely extends to other articulations; it may, however, follow the disease of the other joints. In addition to the stiffness and crackling, &c., there is shortening of the limb, more marked in appearance than reality, eversion, wasting of the muscles of the thigh, but not of the calf; hence the flattening of the nates, more or less spinal curvature in the dorsal region, the convexity being towards the affected side, and the distance between the false ribs and pelvis of that side less than on the other. No pain is produced by firmly pressing the head of the bone against the pelvis.

Anatomical characters.-The head of the femur loses its normal form apparently at the expense of the neck; and the long axis of the neck, instead of passing from below upwards, inwards and forwards, passes backward somewhat, and its right angles to the shaft of the bone, so that the highest part of the head is often below the summit of the great trochanter. The head of the femur, when not eburnated, in the dry state, presents a porous appearance, as if drilled with minute foramina; in the recent specimens these pores are filled up with a very red cellular tissue. In those cases, where the hip-joint was movable during life, the pores were filled up, but none found to project beyond the level of the articular surface; in those, on the other hand, where there was no motion, there was a fine vascular cellular tissue, projecting from them, and covering the articular surface of the head of the femur and interior of the acetabulum, and beneath this no cartilage of incrustation existed.

Knee-joint. From the commencement of the disease the knee-joint is observed to have a strong inclination inwards, which is most evident when both knees are affected; the bones of the leg are rotated outwards, and the foot everted; the patella rests on the outer condyle of the femur, sometimes entirely outside this condyle; when the swelling is at its maximum, in addition to other effects, there is a projection in the popliteal space leaning towards the inner head of the gastrocnemius, disappearing when the knee is flexed, and more tense when the joint is extended, and produced by the distension of a normal bursa connected with the cavity of the joint.

In later stages, the fluid and swelling disappear, the patella takes its proper position, and an articular crepitus is felt, produced by the grating of the rough surfaces upon each other.

Diagnosis.-In white swelling there is more wasting of the limb, the swelling is not well defined and elastic; in chronic rheumatic arthritis the swelling is soft and fluctuating; the cellular membrane around the synovial sac and behind the ligament of the patella is swollen and infiltrated in white swelling, but not so in chronic rheumatic arthritis, when the tendon stands out quite distinct.

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Is & few in masses, the embinatie of pure and sulphen, kr, ralled the Chelsea penalizers elhituary, has proved beneficial after ins see; ao alto the admislased tincture of goalarca. Andres shield be earployed in the form fand to produse least anessiness to the patient. As to mariaced the question whether those affined with this I'vesse should y order, and sondemn temeines, as it were, to immit they should entend against it and persevere in wann eren aithrogh it A to their disproved painful and fatiguing. Dr. Azams replies as follows: for whether commencement of the disease, rest, expping, the frequent use of leeches, con

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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

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