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Medical Times and Gazette.
JOURNAL OF MEDICAL SCIENCE,
LITERATURE, CRITICISM, AND NEWS.
VOLUME 1. FOR 1881.
PUBLISHED BY J. & A. CHURCHILL, 11, NEW BURLINGTON STREET;
ligament and cartilage may take place, but these are ORIGINAL LECTURES.
unusually trivial in proportion to the apparent intensity of the inflammation. It is a matter of astonishment to every
one who watches these cases how surprisingly good reparaLECTURE INTRODUCTORY TO THE STUDY tion is when the attack passes off. In many cases it is not
perfect, but in almost all it surpasses the expectations OF THE ARTHRITIC DIATHESIS.
formed even by well-skilled spectators. I leave aside for the Delivered at the London Hospital.
present certain forms of what are called chronic arthritis, in
which the malady appears to persist, and to produce, by slow, By JONATHAN HUTCHINSON, F.R.C.S.,
uninterrupted processes, great ultimate disorganisation. Senior Surgeon to the London Hospital.
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 It is my purpose, Gentlemen, to bring under your notice, in
maladies are, as a rule, paroxysmal in character and remarka short series of clinical lectures, the peculiar and very im
able for the excellence of the recovery which follows. If portant group of diseases to which our forefathers applied you hear of a man having had repeated and violent attacks the term arthritic. You are well aware that although this of pneumonia, from each of which he has recovered perfectly ; term, used according to strict etymology, means any inflam.
if of another that he is laid up every spring with severe
iritis, yet every summer appears to see nearly as well as matory affection of a joint, yet that, conventionally, it has
before; if of a third that he is frequently the subject of joint been restricted to certain morbid conditions in which a
inflammations, whilst yet he never becomes disabled,- you remarkable tendency is shown for many joints to suffer, may in each case make a safe guess that the malady in and to suffer repeatedly. An arthritic person is one who question was of the arthritic type. The knowledge of this over and over again suffers from inflammation, more or less tendency to spontaneous recovery is of the utmost use to us transitory, of his joints, and who is so liable to it that he
in prognosis. knows what are the influences which are likely to produce an
I have been hitherto speaking of the arthritic diathesis as
if its existence were acknowledged by all nosologists, and it attack. It is thus quite clear that a tendency to arthritis in is time that I should admit that this is in the present day by this sense is a constitutional one. Other diseases of joints | no means the case. The term is a decidedly old-fashioned may be local, but true specialised arthritis, although often
one, and if I venture to ask you to employ it, the duty excited by local causes, always has in the background a con
devolves upon me of defending it and of showing that it is
one based upon clinical fact. In the present day we are stitutional peculiarity as its source. To this constitutional taught to speak of gout and rheumatism as essentially difpeculiarity we give the name of diathesis; and when we say of ferent maladies, yet both come into the old category of anyone that he is the subject of the arthritic diathesis, we mean | arthritis. Respecting rheumatic gout and the various forms that he is in that bodily condition-of that organisation,
recognised under the name of chronic rheumatism, although which renders him liable at some time, and under suitable
there is much difference of opinion and many contradictory
statements extant, yet I believe I am right in stating that prevocations, to become the subject of active arthritic mani.
the balance of authority is in favour of the belief that they festations. It by no means follows that an arthritic man is stand distinct, both from gout on the one hand, and acute always, or even often, suffering from arthritic maladies, any rheumatism on the other. more than that the witty man is always brilliant; it is sufficient Let me here attempt a brief glance at the kind of facts in each case that the basis qualification, the potentiality, be with which in the following lectures we shall have to deal, there. In each it is quite possible that the possessor of such and at the terms by which they may most appropriately be qualification may go through life, and transmit to his succes. designated. Let me also beg of each one of you to be most sors his possession, without having ever himself exhibited it careful in defining his terms, for there will be no hope of in an unmistakable form. Now, although liability to joint our getting to the bottom of a complex question like the inflammation is the feature which gives its name to the present one unless we are studious, on the one hand, to get arthritic diathesis, I must warn you against the notion that clear and vivid conceptions of facts, and on the other, to use it is the only phase by which that diathesis manifests itself. words in reference to them which we all employ in the same It would be strange, indeed, if such were the case, and if it sense. were possible that a constitutional state could exist which The time-honoured name of “gout " is one which is well should give proclivity to inflammation of the joints, and understood, and of which the equivalent has been used from should exempt wholly the other tissues. Although the joints the days of the Romans, with singularly little difference of suffer chiefly, and present the most prominent symptoms by opinion as to the cases to which it is applicable. If the case which we recognise the diathesis, yet they take simply the be well characterised everyone can recognise gout, for its first rank, and by no means an exclusive one. There is no symptoms are most definite, and almost everyone, lay as well structure in the body that may not be attacked. We have, as medical, knows what they are. All that we have said as possibly, arthritic dyspepsia, arthritic renal disease, arthritic to the peculiarities of arthritic maladies finds a most definite pneumonia and bronchitis, arthritic affections of the skin ; | realisation in the case of gout. It is paroxysmal with a it is certain that we have many arthritic affections of the vengeance, and in it suddenness of onset and of decline, fascia, muscles, nerves, and eye. Hence, in part, arises persistency of liability, and comparative freedom from local the great importance of the subject to which I invite your disorganisation, find emphatic illustration. To these general attention.
characters we may add that gout usually attacks the smaller Here we may suitably pause to assert that arthritic inflam joints first, giving, indeed, primal preference to that of the mations, whether strictly arthritic in the sense of attacking great toe, that its acme is marked by great swelling of the joints or otherwise, have a peculiarity of type. This parts external to the joint, by a glossy skin, which pits on peculiarity is such that by it alone their true nature may pressure, and which desquamates when the attack is past, by often be guessed in cases where other points of evidence the most intense pain, and by great disturbance of health, are defective. They are, as a rule, remarkable for sudden more especially of the nervous system. Modern pathological ness of onset, rapidity of development, and certainty of research has given increased prominence to another symp. decline. If, however, there is a strong tendency to spon tom long well known. I allude to the secretion of chalk, taneous decline, there is also one equally strong to future or of a substance which looks like chalk. This salt, the recurrence. There is about them all a here-this-week,-gone white lithate of soda, is formed so constantly in gout that its the-next,-certain-to-come-again-some-time quality, which is presence or absence may, I think, be taken as the line of most characteristic. As a rule, they are all, when at height, demarcation between true gout and rheumatic gout. Unforattended by very severe pain, and relatively to the intensity tunately, it is only in the latter stages of the malady that of the inflammation there is but little tendency to dis the presence of this salt can be proved during the lifetime of organise. Above all, in strong contrast with other inflam. the individual. In advanced cases of gout we may find con. mations, they show no tendency to cause suppuration. cretions about the affected joints or in various other parts, Lymph effusions there may be, and adhesions may result, more especially in the cartilages of the ears. The researches slow alterations in the forms of bones and in the texture of 1 of Dr. Garrod would tend to show that the examination of the
VOL. I. 1881. No. 1592.