The paper of the evening was then read by Dr. E. H. Colbeck, on "AN EXPLANATION OF THE APICAL INCIDENCE OF PULMONARY TUBERCULOSIS." The paper was discussed by the President, Dr. Van Praagh, Mr. Burgess, Mr. Raven, Mr. Kelly, Mr. Coombs, Mr. Nesfield, and Mr. Burpitt. Dr. Colbeck replied, and the meeting concluded with a hearty vote of thanks to Dr. Colbeck for his interesting paper, and to the gentlemen who had shown cases and microscopical specimens. March 12th. The PRESIDENT (Dr. A. P. Luff) in the Chair, and forty-four members present. Microscopical specimens were shown by Dr. John Broadbent, illustrating the blood in Malaria. No clinical cases were shown. The paper of the evening was then read by Mr. V. Warren Low, on "SOME MODERN BULLET WOUNDS." The paper was illustrated with diagrams, and specimens of the various kinds of bullets used in the South African War were passed round. (We print the paper in another column.) The paper was discussed by the President, by Mr. W. Ashdowne, Mr. R. C. Leaning, Dr. H. H. G. Knapp, and Colonel White, R.A.M.C. Mr. Warren Low replied, and the meeting then closed with a very hearty vote of thanks to Mr. Low for his excellent paper, and to Dr. Broadbent for his beautiful microscopical preparations. At the Annual General Meeting which followed, the following new rule was passed : "That the President shall not be eligible for reelection, but that all the other officers of the Society shall be eligible for re-election for a further period of one year." The following is the list of officers for next year : THE CAUSES OF DEATH AMONG THE ASSURED. By CLAUD MUIRHEAD, M.D., F.R.C.P.Edin. 66 Vol. VIII.-No. 5. 80 Books received for Review Announcements Appointments Change of Address Pass Lists The Services ... South African News Special Prize Prize Examinations Publications Received... MAY, 1902. The Testimonial to Mr. Edmund Owen. During the last forty years Mr. Owen has been associated, as Student, Lecturer, and Surgeon, with St. Mary's Hospital. Now that his term of office is almost at an end, and his active connection with the Hospital is ceasing, there are none who will not wish in some way to show him how much we have appreciated his friendship, his teaching, and, if a slang expression may be excused, his ragging." Few students can have left St. Mary's in the last thirty years who have not been submitted to that process, whether in dissecting-room or theatre, and none have passed through the "mill" without having been the better for it. It was not only the Surgery or Anatomy that they learned in the process; more important still were the qualities of promptness, precision, and accuracy, in which they were constantly drilled. His method of teaching was graphically described by Mr. Field: "He slammed and jammed and rammed the facts of Anatomy and Surgery into students until they could not help digesting them." It has been said by one striving after epigram that granulation tissue grew over all his teaching, like ivy on a brick wall, covering and eroding the other facts of pathology. Be that as it may, it resulted in building up in the minds of those subjected to it a solid foundation of the essentials of Surgery, and the man who sat in the "front row consistently could face the ordeal of an oral examination at any time after with equanimity. "The geniality of his presence, the manliness of his personality, the daring of his PAGE 80 81 81 81 81 82 82 82 82 82 Price 6d. the raciness of his stories, these are the qualities," as Mr. Page said, "which have made us admire and love him." While we recognise to the full the distinction of a career which, however high a point it may have attained, is destined, we believe to touch one yet higher, it is the sense of personal loss which will most affect us. And at the meeting held to consider the question of the testimonial there was a very general feeling that the testimonial, whatever form it should take, should be personal, as from friend to friend, a concrete expression of love, appreciation, and regret, and no mere abstract commemoration for the benefit of future generations. We do not at this time intend to enter into any appreciation of Mr. Owen's work. Next month we hope to publish an account by one whose friendship with him is of as old date as his friendship with St. Mary's Hospital. Hospital. What we wish to do at present is to let all Old Students who were unable to be present know that at a general meeting held on May 6th, in the School Library, it was resolved "that a testimonial be presented to Mr. Owen as a mark of appreciation of his eminent services to the Hospital and Medical School during the last thirtytwo years." A large committee, representative of the Staff, Old Students, and Present Students, was elected to carry out this resolution. A formal appeal will shortly be issued by the committee, but so sure are we of the spontaneity with which this appeal will be responded to, that we think it almost sufficient to intimate that the Dean of the Medical School is the Hon. Treasurer, and Mr. Ernest Lane the Hon. Secretary of the Rheumatoid Arthritis.' By CHARLES W. BUCKLEY, M.D.Lond. Rheumatoid Arthritis has only come into prominence of late years as a distinct disease, being formerly generally regarded as a chronic forin of rheumatism, or a combination of rheumatism and gout. This is partly due to the various names which have been given to the condition, and partly to the meagre descriptions given in the text books of medicine, and there is probably no disease which more frequently gives rise to errors of diagnosis. And yet it is no new disease due to advancing civilisation, for skeletons bearing marks of its ravages have been found in Egyptian tombs dating from 1500 B.C., in Pompeii, and in a Roman sarcophagus at Smithfield. It first began to be distinguished as a separate disease at the beginning of last century. In 1804 Heberden wrote on the subject, describing among other features the nodes which are associated with his name. A year later Haygarth followed him and described "nodosities" as a characteristic of the disease. The clinical features were, however, first clearly defined by Charcot in 1853, and his description still holds good. The names which are most commonly used are "rheumatoid arthritis," " osteo-arthritis," "arthritis deformans,” and rheumatic gout, and to this last we owe the confusion which exist in regard to the disease both in diagnosis and in treatment. Theories as to its nature and pathology have been many and varied, each supported by famous names, but while mentioning the more prominent I shall not attempt to discuss them as it would take too long. The nervous theory long held the field, and still finds supporters. It was advanced by Remak, Senator, and Duckworth, but while there was much to be said in its favour it seems to be quite insufficient to account for the acute cases. Ord, who also held the "nervous" theory, considered it was largely influenced by reflexes from the female generative organs. Charcot and other foreign observers believed it to be secondary to true Rheumatism, and certainly many cases give a history of previous arthritis in some form, but others absolutely deny any such history. Forsbrook in 1893 considered that anæmia setting up defective nutrition of the joints thus caused the lesions. During the last few years, however, a microbic theory has been gaining ground. A bacillus has been isolated from the joints by several observers, namely, Wohlmann, Bannatyne, Blaxall, Schuller, Raymond, and Chaffard. It was small and deeply staining at either end, thus resembling a diplococcus, but inoculation failed to produce the disease in animals. Later Von Dungern and Schneider isolated a diplococcus but inoculation again failed. As late as last month, however, Poynton and Payne, whose work on the diplococcus of acute rheumatism is well known, announced to the Pathological Society of London that they had isolated a diplococcus from a case of chronic rheumatoid arthritis, had cultivated it and on injecting the culture into the veins of a rabbit had set up joint changes, non-suppurative and resembling those of rheumatoid arthritis, while the cardiac lesions which had followed similar inoculations with the diplococcus of acute rheumatism were absent. Thus the microbic theory is gaining ground, and will probably soon be definitely established. I have devoted more time to it than I intended on account of its bearing upon the treatment. The disease is not definitely hereditary, it is more common in women in the proportion of eight to one, but it is important to note that before puberty it is more common in boys than in girls, hence the generative functions have evidently an important bearing. In men, however, it is often very severe, in my own experience I think more so than in women. It most commonly sets in between 30 and 50, acute generalized cases being commoner in young subjects, while in older cases it is often chronic and localized: a well marked acute form is seen in children, and has recently been investigated by Dr. Still. Predisposing causes are debility, from hæmorrhage, rapid child-bearing, or prolonged lactation; the menopause; mental anxiety and other emotional causes. Damp and cold are often exciting agents, and the disease is most common in damp climates, especially with a clay subsoil, and it often commences in spring or autumn, when damp prevails and variations of temperature are considerable. Among 293 cases recorded by Bannatyne 55% followed some infective disease such as tonsillitis, influenza, rheumatism, gonorrhoeal arthritis, enteric fever, &c., 25% some disturbance of the female organs, 20% catarrh of the respiratory or intestinal mucous membrane, and 5% injury. As regards the pathology-on opening a joint in the acute stage, the synovial membrane is seen to be dark red, swollen and pulpy, and there is generally a little fluid, though there may be enough to distend the cavity. The cartilages are soft and eroded, with a velvety appearance. The bone is red, rarified, and vascular, later becoming sclerosed, hard and dense with lipping round the articular surfaces, while the inflammatory material in the joint forms adhesions and contracts, thus giving rise to distortion and ankylosis. Loose bodies may be present, either fibrinous in origin, compared to melon seeds, cartilaginous, springing from the synovial fringes, or osteophytes which have become detached. The fluid is straw coloured, viscid and alkaline with clumps of micro-organisms floating therein. Suppuration is very rare-only four cases have been reported. There is often some vacuolation and degeneration of the anterior cornual cells, probably toxæmic in origin, and not in any way causing the joint lesions. Anæmia is present in 95% of cases, the red corpuscles show moderate diminution, the hæmoglobin proportionately more, while the white cells are slightly increased in number. The lymphatic glands show some hyperplasia, and in those cases, occurring in children in which the spleen is enlarged, it is again a simple hyperplasia. Symptoms.-The acute attack may be preceded by any of the disorders already enumerated, and gen monitory symptoms may be noticed, usually presenting themselves as numbness or tingling of the extremities. As such symptoms do not appear to the patient to be of importance we are rarely consulted about them, nor do we often get any history of them. The disease generally starts in the small joints of the hand or foot or both, but it rapidly spreads from periphery to centre, and is usually symmetrical. The swollen joint is ovoid in shape, painful, tender, hot to the touch, and of a dusky red colour, feeling resistant and elastic, and the tendon sheaths and bursæ lying over or in connection with the joint are usually involved. The pain is considerable though not so severe as in gout; it becomes worse at night, and often renders sleep impossible without the aid of powerful hypnotics. There is little constitutional disturbance beyond such as is caused by the fever and want of sleep. Pyrexia, which is never marked, soon becomes limited to an evening rise of from one to four degrees. The joints soon begin to feel soft and pulpy as the disorganisation proceeds, and the extremities look blue and cold and are often bathed in a clammy sweat. Muscular atrophy sets in early and becomes marked, far more so than disuse would account for, and is obviously trophic in origin; it is often accompanied by fibrillary twitchings and cramps, which may be very distressing to the patient. Occasionally petechiæ may appear, and also hæmorrhages under the nails, but other purpuric symptoms are absent. Pigmentation in the form of yellow patches and freckles is often an early symptom, and is almost diagnostic. Enlarged glands are sometimes formed in connection with the affected joints. In the form found in children this is a typical feature, and is accompanied by marked enlargement of the spleen and great wasting, the whole disease being more acute than in adults. The disease may remain in a more or less acute and progressive stage for many months, until the patient is worn out by the constant wearying pain, helpless from the disorganisation of the joints, with perhaps additional misery from the mandibular joint being affected, and wasted to a skeleton, so that his condition is pitiable to a degree. Fortunately, however, we rarely see a case go so far as this, in adults at any rate, since judicious treatment may do much to check this relentless progress. More commonly the disease is arrested either by treatment or by the patients resistance and becomes chronic, and if any other joints become affected it is only in a chronic form. The soft pulpy swelling becomes harder owing to the bony overgrowth, and on movement we get the familiar grating sensation or crepitation, at first fine but soon passing into the coarser forms with great pain and limitation of movement, and ultimately ankylosis and deformity. If the joint has been distended with fluid during the acute stage this is slowly absorbed, with much pain as the ulcerated surfaces come into contact, and limited movement with grating is soon followed by fixation and distortion. The deformities, especially of the hands, are characteristic, and generally follow one of the two types described by Charcot. 1. Flexion of terminal phalanges, extension of flexion of wrist with inclination of fingers to ulnar border. 2. Extension of terminal phalanges on second, flexion of second, extension of first, flexion of wrist and the usual ulnar deviation, radial being much rarer. In the larger joints flexion is the usual deformity, and in the case of the knee backward dislocation occurs. The mandibular joints are often affected and may go on to ankylosis, keeping the mouth rigidly closed, and leading to much discomfort and misery. In a few cases the disease affects the articulations of the cervical vertebræ, so that flexion takes place until the chin almost touches the sternum. The disease may be chronic from the first, especially when commencing in later life. In such cases the larger joints may be alone attacked, often the knees; the disease progresses very slowly but follows practically the same course and leads to the same helpless and crippled condition. Every variety between these two extremes of acute and chronic may be met with, but the very acute form is fortunately rare. The typical deformities may, however, be constantly noticed, and are often regarded as chronic rheumatism. Heberden's nodes, which are often met with in this disease, have small bony outgrowths from the articular surfaces of the bones of the hands, and in such cases it has been stated that the disease often assumes a milder and more chronic form, although much deformity may result. These nodes, which are also present in gout, are probably merely the result of local irritation, and do not point to any intimate relationship between the two diseases. The wasting of the muscles is but slight in the chronic forms, but the skin over the joints becomes thin and glossy, and the joints have, not inaptly, been compared with large chilblains although usually paler in colour. The laryngeal joints and auditory ossicles may share in the disease and become ankylosed, though this is rare. Cardiac lesions occurred in 179% of Bannatyne's cases, the mitral valve being the one affected: pericarditis has also being observed. Tachycardia, to which attention was drawn by Dr. Kent Spender, is by no means constant if pains be taken to eliminate that due to nervousness on the part of the patient, which is very common. Certain skin complications occur, of which purpura and pigmentation have been already described. Scleroderma may occur, and in the form of Morphoa I have seen it well marked. Bannatyne draws an apt comparison between this disease and phthisis-the acute form with its anæmia and wasting, and the disorganisation of joints resembling the conditions in acute phthisis, save that the disorganisation of the lung rarely terminates in cicatrization. The chronic form resembles fibroid phthisis, slight constitutional symptoms and chronic fibrotic change in joint or lung respectively. The treatment also bears out the analogy in striking detail. Diagnosis.-Differential diagnosis is a much simpler matter to talk about than to perforin, and I approach the subject with misgiving. Between typical forms of atypical forms, it is sometimes almost impossible until the case has been under observation for some days. From Acute Rheumatism.-The history of onset and of any former attacks must be carefully investigated; the joints affected are generally the larger ones, and the migratory character is quite typical, whereas in rheumatoid arthritis the affection is progressive generally in a centripetal manner, and once a joint is affected the mischief does not leave it-the joints are also attacked symmetrically, the synovial sheaths and bursae are much swollen. The degree and type of pyrexia and the sweating of acute rheumatism are a useful guide, and the condition of the heart is an important factor. Chronic rheumatism offers great difficulty, but the thickening is round the joints, and fibrous in character, there is not the characteristic crepitus on movement, although there may be some creaking, and muscular atrophy is not present beyond what may be due to disuse. The history of previous attacks and the presence or absence of heart lesions will guide. A form of arthritis of the shoulder joint accompanied by brachial neuritis is not uncommon and may readily be taken for rheumatoid arthritis, but as pointed out by Osler, it is quite a distinct affection, and is in the majority of cases curable. The muscles show some atrophy due to the neuritis, there is great pain and limitation of movement, and occasionally some creaking. Several cases have come to my notice, the majority in women; the neuritic symptoms will act as a guide in diagnosis, but little is known as to its pathology or etiology. A form of arthritis generally affecting one kneejoint or more rarely the ankle joint, also occurs and is commonly described as chronic rheumatism, but is probably either a form of monarticular rheumatoid arthritis, or a distinct disease. I have never seen it in its typical form, affecting two joints at the same time, but sometimes one is attacked and recovers, and the trouble breaks out afresh in the other after months or years. It is most common after middle age, but I have seen it as early as 35. It differs from typical rheumatoid arthritis in that while it is extremely chronic, bony overgrowth is uncommon. It often dates from a chill and the first symptom noticed is generally a difficulty in rising from the sitting position. owing to stiffness, which quickly disappears at first, later it causes decided lameness, but there is generally little or no pain. There is generally fluid in the joint, sometimes in considerable amount causing distention and invading the bursæ which are in communication. I have never found any history of injury, and this together with its slow onset and extreme chronicity excludes simple synovitis. It differs in many respects from typical rheumatoid arthritis, but is, I think, at present generally grouped with it, though it is extremely probable that as our knowledge of the pathology of these conditions increases it will come to be regarded as a distinct disease. Acute gout should offer no difficulty in diagnosis; its mode of outset, the absence of progressive character and symmetry in joints affected, together with the history and habit of the patient should make it clear. Chronic gout owing to its varied forms may offer for as in the progressive form. There is no muscular atrophy, tophi are commonly present, and the teeth are almost always ground down, which in itself is an important point. Charcot's joints and similar nerve arthropathies are generally accompanied by such symptoms as render their nature manifest, and they are usually painless. Simple synovitis may be distinguished by the history, which should clearly point to injury, but may offer difficulty in diagnosis from the chronic nonarticular arthritis to which I have referred. I have known rheumatoid arthritis to be diagnosed as tubercular disease, but I think I need not point out the distinctions. Treatment.-Rest in bed is advisable in the most acute forms until the inflammation and fever have subsided to some extent. As much as possible, however, fresh air and sunlight must be taken advantage of, and an evening rise of temperature need not prevent the patient going into the open air if the sun is warm, and he can remain exposed to it. Exercise is desirable as soon as the patient is fit to take it, either by walking, if the lower extremities are unaffected, or in a carriage or bath chair. Wool must be worn next the skin, and special care taken to keep the joints warm. Diet must be nutritious, and cod-liver-oil should form an essential part of it, if it can be borne in any form at the same time, since many of these patients suffer from dyspepsia, anything aggravating this must be avoided, and cream or "Virol” may be substituted for the oil. In brief the diet must be light, digestible, and of the highest nutritive power. Small meals at frequent intervals are the best, and there should always be some light food at hand to be taken during the night, such as milk, biscuits, chocolate, &c. This will be found to be much appreciated even in chronic cases. As regards drugs the most useful are creosote and guaiacol and their compounds, e.g., creosotal, guaiacol carbonate, benzosol, benzonaphthol, salophen, and salol. Of these creosote and guaiacol are open to the objection that they readily upset the alimentary canal, a most undesirable effect in a disease where good nutrition is of such vital importance. The most useful are guaiacol carbonate and benzosol, but they must be persevered with for some time. General tonics such as iodide of iron and arsenic are sometimes of benefit, and for the relief of the cramps, which may be very distressing, hyoscyamus is useful, while hypnotics are often required. Local remedies are legion, a sure proof of their inefficacy, but patients are apt to attach much importance to them. I have used guaiacol with either iodine (1-6) or olive oil (3-1) as recommended by Dr. Bannatyne, and found it of decided value, while carbolic fomentations (1-40) also will often relieve the pain. Methyl salicylate painted over the joint and covered with gutta-percha tissue is also recommended, and the liniments of chloroform, aconite, and belladonna form an effective anodyne. Extension may be needed to keep the ulcerated surfaces of the cartilages from rubbing together, and will help to maintain a good position in case of ankylosis. Tapping a joint distended with fluid gives much relief |