By ALFRED STILLÉ, M.D.
The treatment of simple acute articular rheumatism may be abandoned to
palliatives and nature. Apart from complications, such cases nearly
always recover under rest and careful nursing. Try and disabuse
yourselves of the idea that their cure is dependent upon medicines
alone; to help nature is often the best we can do. No treatment was ever
invented which stopped a case of acute articular rheumatism. It cannot
be stopped by bleeding, or sweating, or purging, by niter, by tartar
emetic, by guaiacum, by alkalies, by salines, by salicylic acid, or by
anything else. The physician can palliate the pain and perhaps shorten
the attack, can control and perhaps prevent complications and stiffness
of the joints, but he cannot arrest the disease. Where rest, proper
diet, and warmth are enjoined, most cases will get well just as soon
without as with the use of medicinal methods. Dr. Austin Flint, Sr.,
of New York, in support of this statement, subjected some patients, a
number of years ago, to the expectant treatment, and found that they
made just as rapid and just as complete recoveries as did those cases
under the most active medication. Purgatives have been used in all ages
in the treatment of this disease, because it was thought to be a fever.
We are all but too ready to put our necks into the yoke of a theory. In
old times they thought that the system ought to be reduced. Before the
time of purgatives depletion was employed. This mode of treatment I will
not even discuss. There is no evidence of which I am cognizant in favor
of purgatives. There are very good reasons indeed why they should not be
used: (1) Because they cannot possibly cure; (2) because they oblige the
patient to make painful movements; and (3) because they expose him to
the dangers of cold. A celebrated London physician had all his patients
packed in blankets, and did not allow them to move a finger. This was
going to the other extreme. There are certain cases in which purgatives
are alleged to be of use, viz.: Those in which the bowels are
constipated, and there is a bitter taste in the mouth. I have never seen
such cases except in habitual drunkards, and in such cases a purgative
does more harm than allowing the effete matter to remain in the system.
Opium was once vaunted as a specific, and it was claimed that it
diminished the tendency to complications in the course of the disease.
Dr. Corrigan, of Dublin, said that large doses of opium were well
borne--say from four to twelve grains in the course of twenty-four
hours, or sometimes he advised giving as much as one grain every hour.
Opium so employed does not produce narcotism, and does not constipate
the bowels. More recent experience has shown that opium, of all
remedies, is the most likely to cause heart complications. Some have
recommended colchicum, arguing that because it does good in gout, it
must, therefore, do good in rheumatism. But colchicum is not a remedy
for rheumatism. Many years ago it was very much the custom to administer
large doses of powdered Peruvian bark. The rationale of these large
doses was founded upon their sedative effect. Haygrath, Morton,
Heberden, and Fothergill were the first to employ this method. Later
still, a number of noted French physicians, among them Briquet, Andral,
Monerat, and Legroux, renewed the use of this medicine in the form of
quinia, but gave it in smaller doses, seeking only its tonic effect,
from five to fifteen grains being administered in the course of
twenty-four hours, and then it was still continued in smaller doses.
Still more recently, quinia taking the place of Peruvian bark, the old
plan of administering large doses has been resumed. From thirty all the
way up to one hundred grains have been administered in the course of
twenty-four hours. Never was there a more profligate waste of a precious
medicine. Even the physicians who so used it were obliged to acknowledge
that it only did good in sub-acute and mild cases. I believe that it has
also been fashionable in the so called cases of hyperpyrexia to immerse
the patient in a bath varying in temperature from 60° to 98° Fahr.
Although patients thus treated sometimes recovered, they also sometimes
perished from congestion of the lungs and brain.
Among cardiac and nervous sedatives, digitalis, veratrum album and
viride, veratria and aconite, have each, at one time or other, been
employed indiscriminately. Such treatment, of course, has only proven
itself to be a monument of rashness to those who employed it. Such
sedatives may reduce the pulse, but do not shorten the disease. Indeed,
if it is possible to prove the absurdity of anything more clearly by
mere enumeration of these medicines as cures for rheumatism, I do not
know of it. Do digitalis and aconite act in the same manner? This is
just one expression of the folly which surrounded the use of digitalis
at the time of its discovery. Then every affection of the heart was
treated with digitalis.
Within the last few years new remedies have been proclaimed in the shape
of salicylic acid and its sodium salt. I confess that I possess no
personal knowledge of their use in this disease, for I was at first
dissuaded from employing them by a prejudice against the grounds on
which they were recommended, and more recently by the contradictory
judgments respecting them, and the unquestionable mischief they have
sometimes caused. According to their eulogists, the arrest of the
disease is secured by them within four or five days, whether the attack
be febrile or not; its mortality was diminished; relapses do not occur
if the medicine is continued until full convalescence; it is without
influence on the heart complications already existing, but it tends
to prevent them as well as other serious inflammations. One of these
gentlemen assures us that to say it far excels any other method of
treatment would be to give it but scant praise. But, upon the other
hand, it is accused of producing disorders, and even grave accidents in
almost all the functions of the economy. In some cases it has produced
ringing in the ears or deafness, or a rapid pulse, or an excessively
high temperature, panting respiration, profuse perspiration,
albuminuria, delirium, and imminent collapse. In one published case this
anti-pyretic did not lower, but, on the contrary, seemed actually to
raise the temperature so high that immediately after death it stood at
110° F. Many, very many, analogous cases have been published. I repeat,
therefore, that I am personally unacquainted with the effects of this
medicine in acute articular rheumatism, and that I have not thus far
been tempted to employ it.
It may be difficult to see the connection between blisters and alkalies
in their power to influence the course of acute articular rheumatism,
and yet it is certain that they do so influence it, and in the same way,
_i. e._, by altering the condition of the blood from acid to alkaline.
If you ask me to explain to you how blisters act in this way I am
obliged to confess my ignorance. To produce this result they must be
applied over all the affected joints. Experience, if not science, has
decided conclusively in their favor. They do effect a cessation of the
local symptoms, render the urine alkaline, and diminish the amount of
fibrin in the blood.
This brings us to a consideration of the use of alkalies. Alkalies
neutralize the acids, act as diuretics, and eliminate the _materies
morbi_. Alone, and in small doses, they are unable to influence the
course of the disease; but when given in very large doses their effects
are marvelous; the pulse falls, the urine is increased in quantity and
becomes alkaline, and the inflammation subsides. The symptoms of the
disease are moderated, the duration of the attack is shortened, and the
cardiac complications are prevented. The dose of the alkalies must
be increased until the acid secretions are neutralized. A very good
combination of these remedies is the following:
Rx. Sodae bicarb 3 iss.
Potas. acet 3 ss.
Acid. cit f. 3 ss.
Aquae f. 3 ij. [1]
[Transcribers note 1: Could also be '2/3 ij.']
S. This dose should be repeated every three or four hours, until the
urine becomes alkaline. On the subsidence of the active symptoms two
grains of quinine may be added with advantage to each dose. The alkalies
must be gradually discontinued, but the quinia continued. The diet
should consist of beef tea or broth, with bread and milk; no solid food
should be allowed. Woolen cloths, moistened with alkaline solutions, may
with advantage be applied to the affected joints. To these laudanum
may be added for its anodyne effect. The patient must be sedulously
protected from vicissitudes of the temperature and be in bed between
blankets. The alkaline treatment relieves the pain, abates the fever,
and saves the heart by lessening the amount of fibrin in the blood. A
long time ago Dr. Owen Rees, of London, introduced the use of lemon
juice. This remedy was thought to convert uric acid into urea, and to
so help elimination. Though the treatment is practically correct, the
theory of it is all wrong. Lemon juice does good in mild cases, but
cannot be relied upon in severe attacks. During the febrile stage of
acute articular rheumatism the diet should consist mainly of farinaceous
and mucilaginous preparations, with lemonade and carbonic acid water as
drinks. The cloths applied to the joints should be changed when they
become saturated with sweat, and in changing them the patient should be
protected from the air. The sweating may be controlled by small doses
of atropia, from the one-sixtieth to the one-thirtieth of a grain. To
prevent subsequent stiffness the joints should be bathed with warm oil
and chloroform, and wrapped in flannel cloths. In the proper season this
condition is very well treated by sea-bathing. There is no specific plan
of treatment in acute articular rheumatism. The treatment pursued
must vary according to the intensity of the inflammation and the
peculiarities of the patients.--_Medical Gazette_.
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