1000

As regards the articular lesions, though a large number ofjoints may be involved in infectious arthritis, in my experi-ence such widespread invasion is not the rule. What happensin the majority of instances is that at the onset of themalady the disease attacks one, two, or three joints, andhaving done so shows no tendency to involve any otherarticulations, even thoigh we3ks or months may have

elapsed during which the temperature may have been moreor less continuously raised. Now had the condition beenone of acute rheumatoid arthritis it would by that time haveimplicated’ all or a large number of articulations.

Again, the mode of distribution differs; in infectiousarthritis the large joints are by preference attacked, thoughI have known exceptions to this rule in the case of the smalljoints of the hand ; in rheumatoid arthritis the diseasealmost invariably begins in the smaller joints. Again, ininfective arthritis the joint lesions show no tendency to

symmetrical involvement, contrasting with rheumatoidarthritis.With regard to the character of the articular lesions,

nothing can be gleaned from their shape, for the spindle-shaped joints so frequently claimed to be pathognomonicof rheumatoid arthritis are exactly reproduced in cases ofinfective arthritis, when it attacks exposed joints such as thephalangeal. But the overlying skin in infective arthritis

generally shows a definite red blush, whereas in rheumatoidarthritis -it is unnaturally white or bluish in colour. Again,widespread inflammatory cedema of high grade is not infre-quently present in infective arthritis, and forms a veryvaluable aid in differentiation.

Finally, apart from articular lesions we find in acuterheumatoid arthritis, as opposed to infectious arthritis, anabundance of collateral phenomena. Consequently in thosecomparatively rare instances of rheumatoid arthritis in whichthe disease remains for some time confined to the smallarticulations of the hand the following suggestion may provehelpful in distinguishing the case from one of infectiousarthritis. If the opposite hand, hitherto unaffected by jointlesions, is found to be the seat of vaso-motor phenomena,’neuralgic pains, or muscular cramps, the presence of suchwill be in favour of the condition being one of rheumatoidarthritis. While the foregoing, to my mind, constitute thechief-points of distinction between these infective arthritidesand the more acute forms of rheumatoid arthiitis, it mustbe confessed that the dividing line is by no means sharplydefined. In all probability a satisfactory differential

diagnosis will not be available on purely clinical ground,’but on bacteriological data, which it is hoped will soon beforthcoming.

Befo,-e concluding I would like briefly to discuss thoseparticular points, considered by some to forbid any such

sharp line being drawn between the rheumatoid and osteo-arthritic types. I refer, of course, to that very vexed

question-namely, the exact significance of the new bonyoutgrowths occasionally met with in rheumatoid arthritis.

Some observers consider that the presence, even thoughoccasional, of these minor bony proliferations negatives thepossibility of any differentiation between these two jointdiseases. Personally, I am not disposed to agree with thisinference, for the following reasons.

It is generally admitted by most authorities that examples Iof rheumatoid arthritis classically complete in all theirfeatures are constantly to be met with in which no trace ofbony outgr o wths can be detected by skiagraphy. If this begranted, then it seems logical to infer that new bony forma-tions cannot be regarded even as constant, much less asessential, characteristics of rheumatoid arthritis. In otherwords, the new bony outgrowths occasionally met with inthis disease are secondary features or epiphenomena. Asopposed to this, in osteo-arthritis the osseous proliferations,instead of being occasional, are invariable, and integralfeatures in whose absence no diagnosis of the conditioncould be upheld. Again, the bony outgrowths themselvesdiffer widely in the two diseases, being inconsiderable andspicule-like in rheumatoid arthritis, but massive and roundedin osteo-arthritis.

As to the exact nature of these minor bony proliferationsin rheumatoid arthritis, I am not disposed to agree withthose observers who would construe such as evidence of thetransition of a condition of rheumatoid arthritis into one ofosteo-arthritis, but would submit that they allow of a

different explanation. Thus the morbid process in the

articular ends in rheumatoid arthritis is one of rarefaction

and softening. Consequently it follows that by reason ofthis pathological change these structures are peculiarlysusceptible to stresses and strains ; in other words, the endsof the bones tend to undergo plastic adaptations in theirshape as a result of the retraction of the skin and pericapsulartissues, aided by the pull of the related muscles. From aconsideration of X ray photographs I am inclined to thinkthis forms a reasonable hypothesis as to the factorsresponsible for the altered shape in the ends of the bones.Again, Hoffa, in discussing this question, states that thebony proliferations in rheumatoid arthritis, when they occur,are in proportion to the amount of atrophy that has occurred,and he would regard them as reparative’ in nature. Nowwere the proliferative changes in rheumatoid arthritis of thesame nature as those of osteo-arthritis, one would expect thattheir size would be in relationship to the duration of thedisease. On the contrary, it would appear from theanatomical researches of Mtiller, Kachel, and others, thatnotwithstanding the existence of the disease for prolongedperiods, in one instance for over 2U years, bony outgrowthswere absent, whereas in other of much briefer duration slightbony proliferations were present.

Approaching this vexed question now from the ’clinicalstandpoint, it does not appear to me that the existence sideby side, in the same patient, of rheumatoid and osteo-arthritic lesions can be construed as evidence of theiridentity, or that one condition passes into the other. It is

certainly true, as McCrae and others, including myself, haveobserved, that in any given case, while some of the jointsmay be of a rheumatoid type, other articulations in the sameindividual may be of osteo-arthritic character. But suchinstances of the overlapping of the two varieties are com-paratively rare, and, as Goldthwait, in discussing this point,contends, the articular lesions can usually be discriminatedby their onset at different periods of the patient’s life andby their distinctive and widely differing characters.We have an analogy in the case of gout and osteo-arthritis,

the lesions of which, as Hilton Fagge demonstratedanatomically, are to be met with in different joints of thesame individual. We do not in this case therefore presumethat gout and osteo-arthritis are one and the same disease, orthat they graduate one into the other, because theyoccasionally co-exist in the same patient.

Finally, in order to settle this vexed question morespeedily, it is highly desirable that pathological investiga-tions should go hand-in-hand with careful observations, as itis this lack of associated action on the part of the pathologistand clinician that has led us for so long erroneously to

identify these two fundamentally distinct joint disorders,rheumatoid arthritis and osteo-arthritis.Bath.

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Medical Societies.MEDICO-LEGAL SOCIETY.

-Deodands.-Malpraxis in Ancient La,7v.A MEETING of this society was held on March 22nd, Sir

JOHN TWEEDY, the President, being in the chair.Dr. W. WYNN WESTCOTT read a paper on Deodands.

Traces of the custom of declaring an animal or an inanimateobject which had caused a death to be forfeited were, hesaid, to be found among many ancient peoples. In England,Bracton, who lived about 1250, wrote : ’’ Omnia quæ moventad mortem sunt deodanda (" All things which lead to adeath are forfeit to God "). Curious distinctions were some-times made ; for example, if a moving horsed carriage causedthe death of a man both horse and carriage were deodand,but if a man fell from a wheel at rest the wheel only wasforfeit. If an infant under the age of discretion was killedby a fall from a cart in motion no deodand was due, theinfant not being a reasonable creature. In early days theforfeited animal or object or its value was delivered over tothe priesthood, but later, when the king became morepowerful, the forfeit went to the Crown as compensation forthe loss of a subject. This procedure continued until theabolition of deodands in 1846. It was of great interest tonote that this was contemporaneous with the passing of thelaw commonly known as Lord Campbell’s Act for com-

pensating the families of persons killed by accident.

1001

Dr. H. OPPENHEIMER read a paper on Liability for

Malpraxis in Ancient Law. From the earliest periods, hesaid, suffering humanity had been the happy hunting-groundof ignorance and imposture. It was not, therefore, extra-ordinary that from the dawn of civilisation legislators hadfound it necessary to safeguard the sick against ill-treatmentat the hands of those who had undertaken to restore them tohealth and vigour. In ancient Egypt the theocratic form ofgovernment was evolved to perfection, and the practice ofmedicine was restricted to a class of priests who had made astudy of the sacred books of Hermes and were bound to treattheir patients according to the rules laid down therein. If theydeviated from the law they did so at their peril. If whilst

following the rules they did not succeed in saving their

patients they were held free from all guilt ; if, however, theydeviated from the law and were unsuccessful they underwentcapital punishment. As an example of the methods of treatmentAristotle said that the medical priests were forbidden to purgetheir patients before the fourth day of treatment. The harshnessof the law was not so much due to solicitude for the patientas to anxiety to prevent sacrilege, for that was what breachof the rules amounted to, medicine being divine in origin andthe sacred books having been inspired by Isis herself. Inthe ancient Chinese codes it was provided that where a doctordeviated from the established rules and practice, and therebykilled his patient, he should be held excused it it appearedto be simply an error, but should be obliged to quit his pro-fession for ever. If, however, he intentionally deviated fromthe rules, and while pretending to remove the disease of thepatient aggravated the complaint in order to extort money forits cure he should be punished as a thief. If the patient diedthe medical practitioner who was convicted of havingdesignedly employed improper medicines or otherwise injuredhis patient was put to death by beheading. Here, then, as inEgypt, conformity to the traditional rules of practice wasenforced, but as a legal and no longer as a religious duty. Inancient Persia malpraxis had a somewhat different significance:it meant unqualified practice, whether successful or un-

successful, and it entailed the penalty of death by being cutin pieces. A candidate might try his skill upon the commonpeople with impunity, but he could only treat a true believer,a worshipper of the sun, if he had passed the statutory tests.’This was a delightful piece of class legislation in favour ofthe aristocracy ; the same distinction between man and manwas to be found in the laws of Hammurabi, king of Babylon.The code, which was the oldest in existence, contained thefollowing provisions : 218. " If a surgeon has operated withthe bronze lancet on a patrician for a serious injury and hascaused his death, or has removed a cataract for a patricianand has made him lose his eye, his hands shall be cut off."219. "If the surgeon has treated a serious injury of a

plebeian’s slave with a bronze lancet, and has caused hisdeath, he shall render slave for slave." 220. "If he removea cataract with the bronze lancet and made the slave losehis eye’ he shall pay half his value." In the Hindulaw they found the same principles of class dis-tinction, but here the extraordinary regard for alllife which formed one of its tenets had triumphed overanother fundamental principle, the caste system, for the’ordinances. of Manu laid down in quite general terms allphysicians and surgeons acting unskilfully in their severalprofessions must pay for injury to brute animals the lowest,but for injury to human creatures the middle, amercement."In Greece liability for malpraxis did not exist. In Rome,wrote Paulus, he who "brings about the death of the patientis relegated to an island if belonging to the higher classes ; ;but if of lowly rank he suffers capital punishment." This,however, only applied to intentional poisoning. In the

earlier years the physicians were in the position of trades-men of a low grade, but later, thanks to the influx of highlycultured Greek physicians, medicine was converted from atrade into a profession, and the practitioner became re-

sponsible for negligent treatment.

LIVERPOOL MEDICAL INSTITUTION.

Cerebro-spinol Rhinorrhœa.—Appendicitis.—TraumaticNeuroses.

A MEETING of this society was held on March 3lst,

Mr. G. P. MEETING Vice-President, being in March 31st, Mr.G. P. NEWBOLT. Vice-President, being in the chair.- Dr. J. E. McDOUGALL, showed a case of Cerebro-spinal

Rhinorrhœa of spontaneous Urigin. He said that the

escape of the cerebro-spinal fluid from the cavity of the skullin fracture of the base was well known, but that its spon-taneous discharge from the nose in the absence of injurywas very rare. The patient was a man, aged 31 years, whoseillness commenced at the age of 17 years with convulsivemovements of the right arm and leg, with loss of conscious-ness. He had also severe frontal headache. The dischargeof the fluid began nine years ago and persisted for two years.The present discharge had continued for 18 months ; it wascontinuous day and night and averaged a little over a pint inthe 24 hours. The nasal cavity was normal. The fluid gavethe ordinary reactions of cerebro-spinal fluid.-Dr. T. R.GLYNN referred to a case of cerebro-spinal rhinorrhœa

already published.Mr. R. W. MURRAY read a paper on 151 cases of Appendi-

citis that he had operated upon during the last three years.He was of opinion that in the last 20 years the type of thedisease had altered, and that the outstanding features ofappendicitis as met with to-day were (1) the increased

frequency of the disease ; and (2) the increasedvirulence of the poison. He said that as soon as

the diagnosis of appendicitis had been established

arrangements should be made for an operation to be

performed; the trouble was thus confined to the appendix andmight be removed with the appendix. The risks attendingan operation made under these conditions were known to befew ; the dangers of delay were known to be many.-Mr.RUSHTON PARKER said that in some cases the appendixwhen removed showed no outward sign of disease, but onslitting it up a stricture or other alteration was found.

Though early operation had often been justified by thediscovery of even gangrenous change, yet sometimes therefusal to submit to operation had been followed by com-plete recovery and without recurrence. Again, symptoms ofapparent recurrence due to adhesions and the resultinggriping sometimes justified waiting, which was rewarded byrecovery. At operations signs of spontaneous recovery hadbeen revealed and amply explained the disappearance of largeand indurated swellings ; these were commonly noted in thepre-operation days. Even disappearance of the appendix bypartial or extensive atrophy had been thus observed and mightexplain the impossibility of finding it during operation.-Mr.DAMER HARRISSON agreed in considering that the virulenceof appendicitis was greater than formerly.-Mr. F. A. G-JEANS had met with two cases in which he could not findthe appendix.-Dr. J. C. M. GiVBN mentioned two instancesin which the patient was attacked with violent pains in theregion of the appendix ; both patients refused operation andwere perfectly well in 36 hours.

Dr. T. R. GLYNN read a paper upon the TraumaticNeuroses and limited the term to neurasthenia, hysteria, and!bystero-neurasthenia. He gave an historical review of theprogress of knowledge on these states, mentioning the work ofErichsen, Oppenheim, Charcot, Thomsen, Russell Reynolds,and Page. He considered that predisposition from inheri-tance or habit was of great importance, and discussed therelative effect of physical and emotional shock. He instanceda number of examples from his personal experience and foundthat a hystero-neurasthenia was the most common form of theneurosis. He described in some detail the symptoms of theseveral varieties and laid stress upon the period of premedi-tation before the advent in full force of the neurasthenicsymptoms. He contrasted the taciturn behaviour and gloomyappearance of the traumatic cases with the loquacity of theordinary neurasthenic. Dr. Glynn considered the stigmata ofhysteria, and was of opinion that these were rarely if eversimulated. He discussed the prognosis and showed a well-marked example in whom the symptoms had persisted formany years.-Dr. W. B. WARRINGTON said that he thoughtthe historical method was the best way of studying this con-dition. He alluded to the possible organic nature of thesymptoms in some cases. He instanced especially the severesymptoms following injury to the head without fracture ofthe bones, and mentioned that these had in some cases beencorrelated with small multiple vascular lesions. He alsoalluded to the development of a true traumatic myelitis, thesymptoms appearing some time after the injury, and the lesionbeing of a very different nature to that of the ordinary systemdiseases. He alluded to the work of Babinski on the natureof the hysterical stigmata, but could not fully follow this dis-tinguished French physician. Dr. Warrirgton touched upon