CANADA

MEDICAL JOURNAL.

ORIGINAL COMMUNICATIONS.

Lectures on the Pathology and Treatment of Joint Diseases delivered at the McGill University, Montreal. By LOUIS BAUER, M.D., M.R.C.S., Eng. &c.

GENTLEMEN,-In compliance with your gratifying invitation, I propose to discuss some important points pertaining to articular diseases. This is possibly the only subject with which I may hope to engage so distinguished an audience.

The last ten years have been fruitful of material advancement both in the pathology and in the treatment of this class of affections, and their cultivation is still vigorously and diligently pursued. Notwithstanding all the achievements in that direction, the subject still remains in a state of transition, through the tenacity with which one portion of the profession adheres to the venerable teachings of the past, and the enthusiasm with which another portion declares itself in behalf of modern ideas. The time has certainly come when an understanding should be effected by means of unbiassed critical analysis and clinical experience. With this object I enter upon the present discourse. If, through inability, I should fail of realizing my design, I may at least hope to place the subject matter in such attractive relief as to insure your permanent interest and active participation in the settlement of the pending questions.

I.

CAUSATION OF JOINT DISEASE.-On this point, there is a decided clashing of views. By far the larger number of practitioners, the leading members of the profession among them, are of the opinion that most cases of this class are the result of constitutional disorder, of which the articular affection is but the localized symptom. To this theory the most prominent authors on surgery are committed, and it is promulgated from the professorial rostrum and at the bed-side. Time and usage have even rendered it popular with the laity. A few modern enquirers, compara

tively insignificant in name and position, not only take exception to this theory of causation, but assert that articular maladies are excited exclusively by local causes, and that the constitution bears no part in the causation. They further maintain that where the constitution suffers, it suffers from the ulterior effects of the local disease.

As long as etiological views on this subject so widely diverge, there can be no uniformity of treatment; nor can a compromise be effected between views so diametrically opposite. The only way of deciding between two, of which only one can be right, is to analyse the grounds upon which they are respectively placed. I hope the venture on my part in doing so will not be deemed presumptuous, for the conflict of etiology exists, and its settlement is certainly desirable. Too much has been already conceded by the old school to warrant a proud denial; and no party can feel aggrieved when appeal is made to the decision of " stubborn facts."

Scrofulosis, rheumatism, gout, syphilis, scarlatina, pyemia, and other diseases have been enumerated as constitutional causes of joint affections. To strumous disease, however, has been assigned the first rank, inasmuch as it has been linked with the numerous and diversified cases that happen during childhood. From my own experience I have to infer that not less than ninety per cent of all articular affections occur before puberty. Inasmuch as scrofulosis is not limited to childhood, and is supposed to extend beyond puberty, a few more per cent may be added to the original proportion, making a percentage of about ninetyfive. Thus the theory of constitutional causation narrows itself down to the theory of strumous causation, and with this we shall have essentially to deal.

In entering upon our investigation, gentlemen, we meet with the singular fact, that notwithstanding the general acceptance of, and acquiescence in, the stated theory, nobody seems to know accurately what strumous disease really is. There are certainly no two writers that fully agree in its definition, nor does scrofulosis rest upon any firm pathological base. Even its clinical character is rendered so indefinite that implicit faith and a goodly stretch of imagination are required to realize its attributes. This is the status of modern literature on the subject, and in extending our researches over a more remote literary period, we are not less surprised to find that the scrofulosis of the present is a materially different malady from that of the past. The pathological school of the humoralists has identified this disease with a distinct morbid principle, a materia peccans, contaminating nutrition throughout, and stamping all other incidental lesions with its peculiar unalterable

character. The followers of that school very consistently resorted to starvation, vegetarianism, and to mercurial and antimonial preparations, for the purpose of freeing the system of that deus ex machina. With the physiological school the agent of strumous disease was mollified to a more imperfect formation of proteine compounds. They very wisely adopted opposite treatment with a view to regulate the chemical transactions of the body, and to correct the catalytic combinations of the proteine. Both schools accepted perverted hygiene and diet as the remote causes of strumous disease, and consistently believed that it was a disease of pauperism. Again: both schools insisted upon strumous diathesis and an hereditary transmission. These last views are fully compatible with the humoralist principle of pathology, but indefensible from the stand-point of the physiological school. Certain appearances of patients may indicate perverted nutrition, and a morbid principle, thereby engendered, may, like syphilis, be transmitted to generations. But a diathesis for the formation of low-graded proteine combinations is a senseless construction, and the hereditary transmission of such compounds is equally without meaning and inconsistent with the chemical tenacity and restitutive powers of individual life.

Science in its advancement has already made some substantial inroads upon the strumous domain, and narrowed its borders at some vulnerable points. Porrigo capitis and sycosis menti, formerly claimed as specific strumous forms, have of late been proven to be caused by insignificant vegetable parasites. The very prototype of scrofulosis, viz., keratitis scrofulosa, has been reclaimed by modern ophthalmologists as an indepen dent and exclusive local lesion readily yielding to local appliances. And new incursions are threatened from other sides. Help was evidently needed to uphold the loose cohesion of the scrofulous architecture and to save it from pathological downfall. It was but too readily found in tuberculosis. By incorporating the latter with strumous disease, some anatomical tangibility was secured. Gradually the new pathological element has prevailed so completely, that but the name of the old scrofulous doctrine remains. In talking about strumous infiltration, tubercular infiltration is meant; and in fact in its former and present application, the tubercular element has completely superseded the strumous one. The transition from one to the other has been effected so clandestinely as to be noticed but by very few. The alliance between scrofulosis and tuberculosis proves, if anything, that neither had ever acquired a self-sustaining existence. Both diseases are clinically and anatomically different in character. One is said to prevail amongst children, the other amongst adults; and only exceptionally is this rule reversed. The organ

which one chooses is but rarely sought by the other. Their very presumed causes differ most essentially,- -one said to be the result of poverty and sanitary defects; the other having no respect for gradations of wealth and station. They differ even in geographical distribution. Notwithstanding all these differences, they are, by tacit understanding and acquiescence identified as the same disease. It would be unjust, however to say that this transition has been effected totally without opposition. Of late the pathological character of tuberculosis has been subjected to various and close investigations. Its identity with pus has been asserted by Cruveilhier. The results of his experiments upon rabbits demonstrate at least this much, that pus is susceptible of undergoing the very same metamorphosis as tubercle, from the semi-fluid condition to perfect innocuous calcification. The strongest advocates of genuine tuberculosis have been forced to admit that there are often pus corpuscles, where the external appearance of the object denotes tubercular substance. Few authors have had better opportunities of studying the pathological anatomy of bone and joint diseases than Gurlt of Berlin, his investigations extending even over the veterinary field. If I correctly interpret his statement, he has met with no tubercle in joints and bones at all. What other authors had pronounced to be tubercular infiltrations and caverns, he recognised as purulent infiltration the result of osteo-myelitis, and as bone abscess the sequence of circumscribed ostitis. And Virchow, one of the most esteemed pathologists of our time, considers himself justified in stating that tubercle is fully compatible with the acknowledged changes of inflammatory products. Again, gentlemen, is there any peculiarity about tuberculosis that could be established and accepted?

You are aware that the so-called tubercular cell has been asserted, but the microscope has failed to prove its reality. If the microscope cannot substantiate any peculiarity, how much less can the naked eye! For there is certainly no difference in appearance between tubercular matter and cheesy pus, and the suspicion of identity must necessarily accrue from such conformity. At any rate our knowlege on the subject is not final and exhaustive; and we may justly look for further disclosures rather detrimental to, than confirmatory of, the genuine character of tuberculosis.

But, to return to the starting point of our discourse, I shall find ample occasion to show, that the strumous theory in its practical application to articular diseases, is worthless and rather injurious than otherwise, as it certainly has long diverted us from a course of investigation that alone could lead to practical results.

Consistently with the received opinions the lower classes of society

must come in for their full share of joint affections simply because they are supposed to contend with poverty and hygienic neglect. If this assertion had any show of correctness, it would imply that where we find joint diseases, there we ought to expect poverty and hygienic neglect. But clinical experience in a great measure contradicts the assertion. These affections happen in all classes of society. They do not pass the mansions of the rich, nor are the agricultural districts exempt from their visitation. Yet with all it must be allowed that there is, in the abject domestic condition of the industrial classes of Europe, a plausible reason for assuming that they are more subject to chronic derangements of nutrition than the wealthy portion of society. Nor can the action of such nutritive derangements upon local diseases be altogether denied. At any rate, our pathological associations tend to confirm this supposition; though it may be clinically difficult to qualify the exact measure of those constitutional colourings of local lesions. Those who have had the opportunity of personally investigating the actual social status of the European proletariate and pauperism agree that it is deplorable in the extreme. They occupy in cities the worst of dwellings, in the lowest of quarters; their rooms are overcrowded; their articles of food are of inferior quality; multitudes subsist from offal; their opportunities for cleanliness are limited and little resorted to; their very existence is a contest for the necessaries of life. Many of the working classes and paupers domiciliate in places inaccessible to air and sunlight, in damp, and musty basements where but fungi thrive. The combined effects of these unfavorable surroundings upon mind and body are so appalling to the humanitarian as to be remembered with painful sympathy. They give rise to the most aggravated forms of so called strumous disease with which the public hospitals and dispensaries are crowded. It is but natural to associate so conspicuous a morbific agency with a class of diseases seemingly devoid of other causes, and reacting heavily upon the nutritive standard of the patient.

In contemplating the financial condition of the same classes in the United States, we have no difficulty in finding an entirely reversed status. Here the demand for labour far exceeds the supply, and its compensation has therefore for years past been very remunerative, so as to furnish ample income to every individual who aspires to an honest living by handiwork. The "Trades Associations" have, under these circumstances, readily succeeded in controlling employers and in imposing upon them

According to the latest statistics, 10 per cent. of the entire population of Berlin, live in cellars and basements.