ORIGINAL LECTURES. LECTURE INTRODUCTORY TO THE STUDY By JONATHAN HUTCHINSON, F.R.C.S., Ir is my purpose, Gentlemen, to bring under your notice, in a short series of clinical lectures, the peculiar and very important group of diseases to which our forefathers applied the term arthritic. You are well aware that although this term, used according to strict etymology, means any inflammatory affection of a joint, yet that, conventionally, it has been restricted to certain morbid conditions in which a remarkable tendency is shown for many joints to suffer, and to suffer repeatedly. An arthritic person is one who over and over again suffers from inflammation, more or less transitory, of his joints, and who is so liable to it that he knows what are the influences which are likely to produce an attack. It is thus quite clear that a tendency to arthritis in this sense is a constitutional one. Other diseases of joints may be local, but true specialised arthritis, although often excited by local causes, always has in the background a constitutional peculiarity as its source. To this constitutional peculiarity we give the name of diathesis; and when we say of any one that he is the subject of the arthritic diathesis, we mean that he is in that bodily condition-of that organisation which renders him liable at some time, and under suitable prevocations, to become the subject of active arthritic manifestations. It by no means follows that an arthritic man is always, or even often, suffering from arthritic maladies, any more than that the witty man is always brilliant; it is sufficient in each case that the basis qualification, the potentiality, be there. In each it is quite possible that the possessor of such qualification may go through life, and transmit to his successors his possession, without having ever himself exhibited it in an unmistakable form. Now, although liability to joint inflammation is the feature which gives its name to the arthritic diathesis, I must warn you against the notion that it is the only phase by which that diathesis manifests itself. It would be strange, indeed, if such were the case, and if it were possible that a constitutional state could exist which should give proclivity to inflammation of the joints, and should exempt wholly the other tissues. Although the joints suffer chiefly, and present the most prominent symptoms by which we recognise the diathesis, yet they take simply the first rank, and by no means an exclusive one. structure in the body that may not be attacked. We have, possibly, arthritic dyspepsia, arthritic renal disease, arthritic pneumonia and bronchitis, arthritic affections of the skin; it is certain that we have many arthritic affections of the fascia, muscles, nerves, and eye. Hence, in part, arises the great importance of the subject to which I invite your attention. There is no This Here we may suitably pause to assert that arthritic inflammations, whether strictly arthritic in the sense of attacking joints or otherwise, have a peculiarity of type. peculiarity is such that by it alone their true nature may often be guessed in cases where other points of evidence are defective. They are, as a rule, remarkable for suddenness of onset, rapidity of development, and certainty of decline. If, however, there is a strong tendency to spontaneous decline, there is also one equally strong to future recurrence. There is about them all a here-this-week,-gonethe-next,-certain-to-come-again-some-time quality, which is most characteristic. As a rule, they are all, when at height, attended by very severe pain, and relatively to the intensity of the inflammation there is but little tendency to disorganise. Above all, in strong contrast with other inflammations, they show no tendency to cause suppuration. Lymph effusions there may be, and adhesions may result, slow alterations in the forms of bones and in the texture of VOL. I. 1881. No. 1592. ligament and cartilage may take place, but these are unusually trivial in proportion to the apparent intensity of the inflammation. It is a matter of astonishment to everyone who watches these cases how surprisingly good reparation is when the attack passes off. In many cases it is not perfect, but in almost all it surpasses the expectations formed even by well-skilled spectators. I leave aside for the present certain forms of what are called chronic arthritis, in which the malady appears to persist, and to produce, by slow, uninterrupted processes, great ultimate disorganisation. These are very exceptional as to number, and far less so as to character, than they have been supposed, and they by no means invalidate the general statement that arthritic maladies are, as a rule, paroxysmal in character and remarkable for the excellence of the recovery which follows. If you hear of a man having had repeated and violent attacks of pneumonia, from each of which he has recovered perfectly; if of another that he is laid up every spring with severe iritis, yet every summer appears to see nearly as well as before; if of a third that he is frequently the subject of joint inflammations, whilst yet he never becomes disabled,-you may in each case make a safe guess that the malady in question was of the arthritic type. The knowledge of this tendency to spontaneous recovery is of the utmost use to us in prognosis. I have been hitherto speaking of the arthritic diathesis as if its existence were acknowledged by all nosologists, and it is time that I should admit that this is in the present day by no means the case. The term is a decidedly old-fashioned one, and if I venture to ask you to employ it, the duty devolves upon me of defending it and of showing that it is one based upon clinical fact. In the present day we are taught to speak of gout and rheumatism as essentially different maladies, yet both come into the old category of arthritis. Respecting rheumatic gout and the various forms recognised under the name of chronic rheumatism, although there is much difference of opinion and many contradictory statements extant, yet I believe I am right in stating that the balance of authority is in favour of the belief that they stand distinct, both from gout on the one hand, and acute rheumatism on the other. Let me here attempt a brief glance at the kind of facts with which in the following lectures we shall have to deal, and at the terms by which they may most appropriately be designated. Let me also beg of each one of you to be most careful in defining his terms, for there will be no hope of our getting to the bottom of a complex question like the present one unless we are studious, on the one hand, to get clear and vivid conceptions of facts, and on the other, to use words in reference to them which we all employ in the same sense. The time-honoured name of "gout" is one which is well understood, and of which the equivalent has been used from the days of the Romans, with singularly little difference of opinion as to the cases to which it is applicable. If the case be well characterised everyone can recognise gout, for its symptoms are most definite, and almost everyone, lay as well as medical, knows what they are. All that we have said as to the peculiarities of arthritic maladies finds a most definite realisation in the case of gout. It is paroxysmal with a vengeance, and in it suddenness of onset and of decline, persistency of liability, and comparative freedom from local disorganisation, find emphatic illustration. To these general characters we may add that gout usually attacks the smaller joints first, giving, indeed, primal preference to that of the great toe, that its acme is marked by great swelling of the parts external to the joint, by a glossy skin, which pits on pressure, and which desquamates when the attack is past, by the most intense pain, and by great disturbance of health, more especially of the nervous system. Modern pathological research has given increased prominence to another symptom long well known. I allude to the secretion of chalk, or of a substance which looks like chalk. This salt, the white lithate of soda, is formed so constantly in gout that its presence or absence may, I think, be taken as the line of demarcation between true gout and rheumatic gout. Unfortunately, it is only in the latter stages of the malady that the presence of this salt can be proved during the lifetime of the individual. In advanced cases of gout we may find concretions about the affected joints or in various other parts, more especially in the cartilages of the ears. The researches of Dr. Garrod would tend to show that the examination of the |