A Treatise on Rheumatic Gout, or Chronic Rheumatic Arthritis of all the Joints. By ROBERT ADAMS, M.D., A.M., Ex-President of the College of Surgeons in Ireland, and of the Pathological Society; Surgeon of the Richmond Hospital, Dublin. Illustrated by Woodcuts and an Atlas of Plates.London, 1857. 8vo, pp. 362.

THE Volume presented to us by Dr. Adams "embodies the substance of clinical lectures" on rheumatic arthritis, delivered by him to the pupils of the Richmond Hospital during a series of years, and "comprises the principal part of various communications" he has from time to time published relative to this disease. Consequently, he observes it cannot be expected the work will be found to suggest much that is new, or that has not already, by himself or by others, been laid before the profession. But we must do Dr. Adams the justice to state, that having carefully collected from the various medical periodicals all the information on this subject, and having added this to his own experience, he has produced a work complete as far as it goes, on the characters and effects of this disease-a volume which well deserves the careful perusal of every practitioner.

"Chronic Rheumatic Arthritis," is the term Dr. Adams has selected to designate an affection of the joints which, whether following gout or rheumatism, or what authors term "Rheumatic Gout," has long been known, and will be found described by Cruveilhier and some few others, as a chronic, unmanageable, distressing, and persistent malady, affecting the articulations, and rendering the sufferer in every sense of the word "crippled " in his joints. Every one familiar with the dissecting rooms of London hospitals, has had opportunities of examining every species of joint, in every stage of the disease described by Dr. Adams; and we can individually bear testimony to its frequent occurrence amongst the poorer classes of this metropolis, and to the accuracy of Dr. Adams's descriptions of the disease affecting the various articulations of the body. How far the terms "Rheumatic Gout," or "Chronic Rheumatic Arthritis," are justified in their application to this malady, may be questioned by several of our readers; but, in justice to Dr. Adams, we must remind them that he confesses to the difficulty of

proposing a name entirely unobjectionable. Dr. Barclay, in his recent work on Medical Diagnosis,' speaking of rheumatic gout, says:

"We cannot refuse a separate place in our classification to a disease which, though its place in pathology be as yet undetermined, is very well marked in particular cases. The peculiar twisting and distortion of the joints in persons who have suffered for any length of time from its effects, is such as cannot pass unobserved by any one who is familiar with the aspect of disease.

"In its early history it partakes most of the character of subacute rheumatism. It differs from an acute attack chiefly in the absence of fever, and in the circumstance that comparatively few of the joints are under its influence at the period of its commencement; there is a good deal of swelling, and perhaps of redness, of one or two joints, but these are not marked by the extreme tenderness and pain so distinctive of rheumatic fever or of gout; while the local inflammation is more decided than in the subacute form of the disease, if we except a few cases which we have characterized as abortive attacks of acute rheumatism. If due consideration be given to these circumstances, the practitioner will be prepared for the incursion of a most inveterate and most hopeless malady. And let it be remembered, that diagnosis has in this case very much to do with prognosis; where we recognise rheumatic fever, we know that, except the heart become implicated, the patient will be in a few weeks at most as well as ever; and that he is not very much more liable to a second attack than his neighbour. When gout is clearly established, we are sure that the patient will be, for a time, in better health than usual, after the present pain and distress have subsided; but that all the care possible will scarcely serve to ward off a second attack. When we have only subacute rheumatism to deal with, we look for either a trivial and passing affection, or for a lingering illness, as we find less or more of local action; but with rheumatic gout we ought to know that our patient is exposed to protracted suffering, and is liable to remain a cripple for life. When this is not foreseen, much discredit may unnecessarily be brought on the profession-much undue praise be given to the quack, into whose hands such cases are very apt to fall; he will not scruple to throw on the regular attendant the blame of all the mischief which has happened, and claim for himself the credit of any improvement which, under favourable circumstances, nature herself may slowly produce.

"As the disease proceeds, its peculiar characters begin to develop themselves; the swelling subsides in some measure; the redness, if any, is gone from the joints first attacked, but they remain stiff, tender, and useless; while others, in succession, become the seat of inflammatory action; until at length the unfortunate patient is reduced to a condition of utter helplessness. When convalescence has slowly been established, as it may be after either months or years of suffering, considerable distortion and permanent stiffness are the invariable result."

The symptoms of this disease, like those of chronic rheumatism, sub-inflammatory in their nature, are located in the joints, whether small or large; but the disease certainly appears to possess this one peculiar characteristic of clinical importance, that it will be found sometimes to be simply local and affecting but one joint, and that in all probability the hip or the shoulder; or it will be constitutional, and affecting any and several of the joints. In the latter case it generally pursues a steady, undeviating, and deteriorating course, rendering the patient in time crippled and helpless. In the former case the disease will most frequently be traced to some local injury, or to long-continued and excessive exercise or exertion. When constitutional, it will often be attributed to some attack of rheumatic fever which has continued on to a chronic state, accompanied with gradual rigidity of the affected joints. Dr. Haygarth, one of the first to draw attention to this affection, considered it as "one of a peculiar nature, and clearly distinguishable from all others, by symptoms manifestly different from gout, and from both acute and chronic rheumatism."

In what pathological changes does this malady differ from the other inflammatory affections of articulations? Dr. Adams has most carefully noted the former, and in the following order describes them: viz., those which occur-1. In the fibrous and synovial tissues; 2. In the cartilaginous and fibro-cartilaginous; 3. In the osseous structures.

In order to detect the primary alterations in the fibrous and synovial membranes, it is necessary to examine an articulation in the early stage of the

disease-in which case the capsular covering and the lining membrane of the joint afford evidence of chronic inflammatory action. The sac will be more or less distended with fluid, and the membrane itself thickened; the synovial lining will present a red colour, and "vascular tufts, red and hypertrophied synovial fimbria, will be seen in the joint." At a later stage the fluid is less in quantity, but the capsule more dense, and hypertrophied to such an extent, that the capsule of the hip-joint sometimes resembles, in structure and thickness, that of intervertebral cartilage, and frequently has deposited in its fibres masses of bony structure. The cartilaginous and fibro-cartilaginous portions of the joints become affected as the disease advances, and will be invariably found considerably deteriorated in the latter stages of this affection. The articular cartilage becomes by degrees worn off, leaving the surface of the extremities of the bones entirely divested of their natural covering. The inter-articular fibro-cartilages in their respective joints also disappear; "not a vestige" of them will be found in the joints in which they naturally exist, "if they have been long and severely affected by the disease."

The inter-articular ligaments will also be found, under similar circumstances, almost entirely wanting, or softened, shreddy, and torn; the round ligament of the hip, or the long head of the biceps, afford ample evidence of this damaging pro

cess.

Dr. Adams mentions that the semilunar cartilages of the knee-joint sometimes become hypertrophied, or even partly ossified; but as a general rule, it will be found that, as with all other interarticular fibro-cartilages, so are they more affected by the process of absorption than by that of hypertrophy.

With the alteration in the condition of the fibrous, synovial, and cartilaginous tissues, are combined the very interesting development and growth of the "foreign bodies" within the joints; of cartilaginous growth, and sometimes becoming osseous, they have been found in most of the joints in various numbers; they may be either in immediate contact with the synovial membrane lining the wall, or growing in some fringe or prolongation of the lining membrane into the cavity of the joint. When detached, as they frequently are by accidental circumstances, they constitute the "loose cartilages" of joints, the simple existence of which in any joint, Dr. Adams looks upon as but a symptom of rheumatic arthritis in the individual affected. Cruveilhier, Haller, Morgagni, have each noticed the presence of these "foreign bodies," and in most of the articulations. Dr. Adams's remarks on their formation and progress are clear and practical, and our experience, after the examination of many cases, entirely supports all he says on the subject.

The changes undergone in the osseous system affected by this malady, are almost entirely confined to the articular extremities of bones, and are remarkable in the substitution of the ivory-like enamel over their surfaces for that of healthy natural articular cartilage. But there is one peculiar difference between some of the conditions affecting the articular extremities of bones-i.e., between those bones which form ginglymoid joints, and those of the enarthrodial variety. In the latter, the socket becomes deepened by osseous and fibroid deposit round its margin, and the head of the round bone becomes expanded and enlarged in an equal proportion; whereas in the hinge joints, the trochle by their constant friction in time wear away the corresponding surface of the opposed bones, and thus form grooves for their reception. The lower extremity of the femur will often be found worn into ridges, and the articular surfaces of other bones similarly irregular. The shafts of bones are sometimes affected in this disease, though much less frequently in proportion to their epiphysal extremities. When this is the case, they will be found enlarged in different parts, and their structure rendered dense and heavy. Dr. Adams mentions an interesting case, in which the ramus of the lower jaw-bone was found to be an inch longer on one side than on the other, the corresponding condyle being three times the size of its fellow.

The chapter On Treatment is the only really defective portion of this volume,

We are disappointed with the superficial manner in which the author disposes of it. The few observations made by him are to the purpose, but with his experience of the disease, we think he might have entered more minutely into the question of therapeutical assistance. In our own experience, the administration of colchicum and blue pill in the early stages, with the continued use of the iodide of iron, has proved of much benefit, and given considerable comfort to the patient. We should have been more satisfied, and perhaps the subject would have been better elucidated had Dr. Adams informed us, what were the results of the chymical and microscopical examinations of the altered tissues, or whether Dr. Garrod's uric-acid test had been employed in any of the earlier stages of the disease; for there is an ample field for investigation and improvement, in the question of treatment in the earlier conditions of this grave malady.

Dr. Adams commences with the special consideration of the disease affecting the hip-joint, in consequence of the latter being the joint most frequently attacked; and as he considers the profession are more familiar with its occurrence in this locality. His observations here are highly practical, and well deserve attentive perusal. More particularly does he point out the importance of careful examination in such a case, in order to avoid the mistake apt to be made-and one which often has been made-between the effects of the disease on the head and neck of the femur, and the conditions resulting from the fracture of this part. The distinctions, also, between scrofulous affections of the joints, sciatica, &c., are well considered. When confined to the hip-joint, it appears from Dr. Adams's experience that the disease seldom exhibits itself under forty years of age; but we well know that, when of a constitutional character, neither youth nor age is any protection against its ravages.

The disappearance of the ligamentum teres in the advanced stages of this disease, is analogous to the process of absorption and destruction in other joints, in which either inter-articular ligaments or fibro-cartilages exist; and points to the fact, that though the disease may be confined to this one joint, and so far considered a local malady, yet in all its features and effects it strictly adheres to rules, by which we may be said to detect its constitutional character, when implicating any or all other articulations. We see the same thickening of the capsular covering whether the disease be found in one or many joints. There is the same expansion of the heads of the bones, and corresponding enlargements of their sockets; there are the deposits of bony masses round the margins of the articular surfaces or cavities: we find the same thickening, vascularity, and prominent fringe-like projections of synovial membrane; we observe the usual absorption of articular and inter-articular cartilage, and the eburnation and grooving of articular extremities of bone after the disappearance of articular cartilage; and lastly, we invariably find uniform absence of all evidence of suppuration. The consideration of the changes in the shoulder-joint when affected by this disease, taken next in order, forms a very interesting chapter. There, is, however, only one point to which we need draw attention. It is invariably found-at least so frequently is it the case that we may lay it down as a rule-that when the shoulder is affected, and the disease continues and increases, the tendon of the long-head of the biceps muscle (the intra-capsular) portion becomes shreddy and worn away, and at last entirely cut through, analogous to the destruction of the ligamentum teres. Attendant upon this condition, a partial displacement of the head of the humerus occurs upwards; the deltoid, no longer restrained in its shifting action, draws the head of the bone partially over the upper margin of the glenoid cavity, and in contact with the under service of the acromion and coraco-acromial ligament; the under surface of these parts becomes covered with an ivory-like coating, whilst a corresponding change takes place in the opposed surface of the head of the humerus. Dr. Adams carefully indicates how readily this condition, the result of disease, may be mistaken for the effects of an injury; and though the true nature of these cases has been known for some time to many surgeons, and though we have personally examined and satisfied ourselves in many instances of the true character

of this lesion, we quite agree with Dr. Adams, that hasty conclusions have frequently allowed practitioners to mark it down as a partial dislocation, following an accidental displacement of the biceps tendon. It is not necessary for us to enter more minutely into this question, but we venture to express a hope that Dr. Adams's careful summary of this disease affecting the shoulder-joint, will be well studied by every one interested in the pathology of diseases of the joints. One case of this partial dislocation is mentioned on the authority of Professor Smith of Dublin, in which the long tendon of the biceps was found

"In its place, and both it and the capsular ligament in this instance maintained their continuity, the loss of which has been referred to as the lesion permitting of the displacement upwards of the humerus."

The numerous cases that have occurred in the Dublin hospitals and workhouses, have enabled Dr. Adams to draw up a very complete list of the various diseased conditions in all the articulations of the body, and cases are given in the work which illustrate every variety.

One interesting fact remains to be mentioned, which is, that in this disease, as the mischief advances in a joint, there appears to be a tendency, in some bones, to a separation of the epiphyses from the body of the bone, long after ossification must have consolidated the pieces together. This is especially observed in the acromion, and Dr. Adams has in his illustrations shown several specimens of it. We cannot conclude our observations, without drawing attention to the remarkably well-illustrated specimens of diseased joints, which accompany the volume in a separate atlas, and which have been produced regardless of expense. They are most truthful in detail and abundant in character; they form a most valuable addition to Dr. Adams's work, and the profession have much to thank him for, in preparing and presenting to them such interesting and instructive volumes.

REVIEW III.

1. Fifteenth Annual Report of the Registrar-General of Births, Deaths, and Marriages in England.-London, 1855.

2. The Census of Ireland for the Year 1851. Eleven Volumes. Presented to both Houses of Parliament by command of her Majesty.

3. A Selection from the Physiological and Horticultural Papers, published in the Transactions of the Royal and Horticultural Societies. By the late THOMAS ANDREW KNIGHT, Esq.-London, 1841.

4. An Account of some Experiments on certain Seaweeds of an Edible Kind. By JOHN DAVY, M.D., F.R.S. (Edinburgh New Philosophical Journal,' New Series, vol. iv.)

In a former article we passed in review the last Census of Ireland chiefly in relation to its bearings on medical science. It was then seen how direful were the effects of famine, owing to failure of the main article of sustenance, the potato, in reducing an excessive population; and also the happy consequences resulting from the removal of that excess, and the introduction of a more varied diet, in increasing the prosperity of the remainder.

As a correlative subject, we propose now to consider briefly the food of the people, viewing it in its greatest generality, affecting as it does the whole human race for weal or for woe. As preliminary, it may not be amiss to advert to the animal, man, and his structure-the very elementary part of the subject. We are told in holy writ that man's destiny was to people and subdue the earth, not spe