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DEATH OF DR. LAPPONI.-Late in December the death of Dr. Lapponi was announced in Rome. It will be remembered that the doc tor came into much prominence on account of his relation to the late Pope Leo XIII. at the time of his last illness.

Charles T. Cutting, M. D., of Auburndale, announces the opening of a Boston office at 141 Milk Street, where he will devote special attention to railroad and casualty work in the position of examining surgeon.

NEW MEDICAL EXAMINER FOR SUFFOLK COUNTY.-It is with much gratification that we learn of the appointment of Dr. George B. Magrath as medical examiner for Suffolk County, the position recently held by Dr. F. H. Harris. Dr. Magrath has had an unusually good training to qualify him for the position just received, being a graduate of Harvard College and of its Medical School. He has been pursuing pathological studies and investigations for many years in some of the various laboratories of the city, and since September, 1905, has been assistant to Dr. Charles Harrington, secretary of the State Board of Health. We extend to Dr. Magrath our congratulations and feel sure that the appointment is one that should give universal satisfaction to all concerned.

THE museum of Boston University School of Medicine is the recipient of a donation by Dr. Horace Packard, consisting of his valuable collection of gall stones and appendices. The latter series is particularly desirable as it includes practically, every form of inflammatory condition and demonstrates very clearly the etiology of the disease as explained by Dr. Packard.

AN Anti-Tuberculosis Congress is to be held in Minneapolis, Minn., February 2-12. The program is unusually comprehensive, comprising the Western Conterence on Tuberculosis, the Minnesota State Association for the Relief and Prevention of Tuberculosis, and the American Tuberculosis Exhibition. The subject of tuberculosis will be discussed from all possible standpoints.

NEW MEDICAL JOURNAL.-The new year brings to our desk the first number of the Long Island Medical Journal, a new publication edited by Dr. P. M. Pilcher. This is to be the organ of the associated physicians of Long Island, in which the papers of that association will appear instead of in volumes of transactions as heretofore. This first number is arranged with much attractiveness, is clearly printed upon good paper, and is welcomed gladly into the medical arena.

THE magazine long known under the name of the Journal of the Association of Military Surgeons appeared in January, 1907, as the Military Surgeon. The publication is the same, the only change being in the name. This was the first military medical journal to be published in the English language. It therefore entered upon a new and unexplored field. That it has been successful to a most satisfactory degree during its life of six years is well known. We trust that the venture may see a continuation of the good works of the past, and extend to it our cordial good will.

SUPERINTENDENT OF RUTLAND SANITARIUM.—It has recently been decided to do away with the position of visiting physician for the Rutland Sanitarium and to appoint instead a regular resident medical superintendent. Dr. F. L. Hills, of Concord, N. H., who has had wide experience in administrative work of various institutions, has been appointed to the position.

Dr. D. A. Strickler, of Denver, Col., president of the State Board of Medical Examiners and of "Progress," was married in December to Dr. Mary M. Bradner, one of the most prominent dentists of Denver. Dr. Strickler, in addition to his literary work, is well known as an eye and ear specialist, and stands high in the profession. The Gazette extends to the happy couple its most hearty congratulations.

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BY WILBERT B. HINSDALE, A. M., M. D.. DEAN OF THE HOMOEOPATHIC
MEDICAL DEPARTMENT, UNIVERSITY OF MICHIGAN, ANN
ARBOR, MICH.

When examining a diseased person for the first time, and unfortunately too, often for the last time, the question is raised audibly or mentally or in both ways: What is it? If there be complaint of pain, swelling, withering, discoloration, impajrment of function, one, several or all, in or around a joint, the old term "rheumatic" will hardly diagnose any longer. It may temporarily satisfy the sufferer and his friends, but, in fact, if it expresses anything, it little more than repeats in another word what has been complained of: that is, the member aches.

On account of the uncertainty of their causes, in no class of cases is there more confusion in classification than in involvements of articular and peri-articular structures. The analytical method in diagnosing should be applied with care, as conclusions must be drawn almost entirely from clinical evidence. Of course, many times the explanation is apparent, at other times, after the closest discrimination, it rests only upon a tentative basis.

Having regard for the patience and time of the bureau that I shall consume, I will not attempt to survey the entire field suggested by my subject, but will confine my remarks almost entirely to chronic rheumatism. I do not care to have my consideration of it designated a paper upon chronic rheumatism but, better about chronic rheumatism. Chronic rheumatism may be very difficult to define and mysterious in its etiology, but it is not rheumatism. However, since certain painful conditions of muscles, joints and nerves have been designated by that term, it seems necessary to retain it, at least, provisionally. A case of acute rheumatism may be unusually prolonged, but it never becomes chronic in the true sense of the word, any more than

*Read at the International Homœopathic Congress, Atlantic City, N. J., September, 1906.

measles or typhoid fever. Certain pulmonary or ophthalmic conditions may follow measles and permanent intestinal lesions or peripheral neuritis follow typhoid fever, but we do not call them either chronic measles or chronic typhoid fever. Acute rheumatism may excite fibrous thickening or valvular impairment, but these are not an indefinite continuation of the disease: they are its sequelae. They are not rheumatism become chronic. They do not make up the grouping of symptoms that is characterized by the term chronic rheumatism as here used, which on account of long usage, though by mistake, is a phrase of convenience and not of definition.

Since "chronic rheumatism" is not rheumatism, it may be well to give expression to the prevailing views upon the subject. The essential pathological changes are confined to white fibrous tissue, and only rarely, and then in advanced stages, is it associated with changes in articular cartilages or in bones. This point is of great differential diagnostic value. The white fibrous tissues being so generally distributed throughout the body in tendons, periostium, fascia, ligamentous structures and the sheaths of muscles and nerves, changes in it interfere with locomotive functions and produce pains along nerve-trunks away from, as well as near, articulations. The pains are sometimes aching or "rheumatoid;" again, sharp and piercing or "neuralgic."

In a brochure upon this subject, Doctor Ralph Stockman of Glasgow University gives the pathology somewhat as follows: The irritant produces a local inflammation and serous exudation, causing tenderness and soreness. At first the exudate may be resolved by manipulations, but upon slight provocation it tends to recur. Many times there is tumefaction, which may be seen and felt. This stage of incipience is the time when mechanical manipulations like massage produce comforting results. Finally the exudate becomes permanent and involves portions of aponeuroses or sub-cutaneous fibrous tissue. Sometimes fibrous bands form, at others, nodules. Stiffness, pain and more or less unnatural shape of body or limb are present. The pain is produced by the local tension causing pressure upon nerve filaments. If a nerve sheath have running through it a fibrous thread, the pain is lancinating. Probably many so-called cases of sciatica are of this nature. One fibrous nodule in the lumbar region may produce a very obstinate and painful lumbago. Under the irritating influence of cold, damp, exertion, sudden changes in barometric pressure, indigestion and unknown toxines, the indurations swell, become tenser, aggravating the stiffness. Aching, neuralgic pains result.

Chronic rheumatism is not a diathesis: it is a local manifestation, perhaps only a symptom, of some microbic or toxic invasion conveyed by the circulation, sometimes confined to local areas, again widespread throughout the susceptible tissues of the body. In studying the etiology of diseases the hypothetical dia

thesis is becoming more and more unnecessary. Except that a person has the disease in fact, how can it be told that he has a disposition to rheumatism?

There seem to be some accidental and environmental predispositions to chronic rheumatism. One is rheumatic fever; others are pharyngitis, influenza, muscular colds, over-exertion, exposure to extremes of temperature and moisture, and indigestion. By some, great stress is laid upon poisons arising from intestinal fermentation and putrefaction as a cause.

The foregoing seems to afford a few characteristics in cases, as they usually occur, different from rheumatoid arthritis, arthritis deformans, senile arthritis, especially from arthritic inflammations metastating or accompanying the infectious fevers, arthritis associated with pyogenic infection, gout, osteo-arthritis, traumatism, the involvement of joints in organic nervous diseases, myalgia, neuralgia, etc. One or two of these have been pointed out; but to present them connectedly, the following is submitted: In case the beginning exudate and lumpy formations be situated so that they can be detected by physical examination, which procedure should never be neglected, they should be noted. Points of tenderness are guides to their location. While the joints are usually the storm-centres of the irritation, the pains are not by any means always localized there, as they may occur wherever white fibrous tissue is distributed and are apt to be neuralgic in character. Ocipital neuralgia is often due to a nodule in the neck, brachial neuralgia to nodules in the upper arm. The commonest situations for the indurations are lumbar aponeurosis, the fascia lata. tendinous expansions of the thigh muscles, the calves,, the trapezius above the supraspinous region, the glutei, the deltoid, the soles of the feet, the intercostals. Synovitis is not often present, except in advanced cases. The bones are seldom involved; ankylosis results, when present, from disuse or atrophic changes due to disuse and pressure by the thickened fibrous tissue embarrassing the nutrition.

It is slow in developing. Osteophytic deposits do not occur as in arthritis deformans. There are no cardiac complications. Oftentimes the sufferer moves with more ease and less pain after continued exertion. So soon as the exudates can reaccumulate in their former location after rest, the pains get worse. While the danger, so far as life is concerned, is not great, the disease is essentially chronic, as the present name signifies. The pains at first being ameliorated by good weather, modified exercise, rest, improved hygienic and dietetic conditions, tend to be more frequently recurrent and finally the patient lapses, after a few months or years, into chronic invalidism, stiff, decrepid and stooping in posture. The nodules harden and may be removed surgically, often with great relief to the sufferer, if situated within an operable field. Considerable is claimed for surgery in certain cases. As compared with the numerous joint

disorders or pseudo-rheumatism following rheumatism, diphtheria, mumps, scarlet fever, meningitis, typhoid, erysipelas, dysentery, the puerperium, gonorrhoea, syphilis, it is not sudden in its onset, and it is unaccompanied by the immediate history of those infections. The proclivity of the joint tissues for the irritants of or arising from the specific infections seem to be considerable.

If the patient be a child, it must be borne in mind that tuberculosis at that period of life has a marked fondness for synovial membranes. Upon his first complaint, the probabilities must be considered with reference to family history, personal history, general physical condition, involvement of the lymphatic glands, always bearing in mind that tuberculosis may be primary in many kinds of tissues and can be so in synovial as well as in pleural membranes. The arthritis of tuberculosis, like that of gonorrhoea, is likely to be monarticular and in case of a child. should receive the benefit of doubt. The greater number of diseases localizing in synovial and tendinous tissues incident to older persons can be excluded in children. It would be interesting to dwell upon the distinguishing features of tubercular arthritis in detail, but since it is so often advanced into the surgical stage before detected it will be passed by with few more words. Reference has been made to it because it presents so many aspects for investigation. Perhaps in no one type of diseases do the environmental, physical, subjective and microscopical evidences conspire more agreeably to a diagnosis. Chronic rheumatism appears to belong to a group of diseases primarily the result of irritants associated in some way with infection. Admitting the etiology to be obscure and that very much is to be found out before we can speak with assurance, we are forced to the conclusion, as in acute rheumatic fever, so far as the cause or causes are concerned, except in comparatively few instances, that nothing is known beyond conjecture. Opinions, as far as expressed, by those who are giving special attention to the study, are confusing if not conflicting. However, following the general trend of reasoning now in vogue with pathologists, a large number are assigning either some undiscovered infections or intoxications as the probable exciting agents. If the hypothesis that certain types of arthritis are excited by germs, germ-and auto-intoxications, becomes an established fact, it will likely also be possible to classify them according to a scientific principle. A provisional, mystifying nomenclature will then give place to one upon which dependence can be placed.

No one seems to claim that infection and intoxication account for all forms of arthritis, some of which resemble in certain respects chronic rheumatism. It is stoutly held by some that arthritis deformans is of neurotrophic origin and that they get the best results from treatment by so considering it. It is

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