correctly, trimethylamine--as a remedy for acute and chronic rheumatism
by Awenarius of St. Petersburg in 1856, by Gaston of Indiana in 1872,
by Dujardin-Beaumetz in 1873, and Peltier in 1874 (both of France), and
Spencer of England in 1875, it has not been much employed, especially
since the salicylates have attracted attention. It appears that in a
considerable proportion of cases the articular pains have subsided in
two or three days under its employment, and then the temperature has
declined, but the visceral complications have not been prevented. From
4 to 8 minims of trimethylamine in an ounce of peppermint-water, with a
drachm of syrup of ginger, may be given every hour or two, the
intervals to be increased as the pains diminish. When pain has quite
ceased the drug may be stopped and quinia given its place. It merits
further study in this disease,[193] and Dr. Shapter of the Exeter
Hospital has very recently stated that he is so convinced or the value
of propylamine that salicylic acid has not fully commended itself[194]
to him. Senator has recently recommended benzoic acid or its sodium
salt in large doses (about ounce ss in the day) in those cases of acute
rheumatic arthritis in which {63} the salicylates have failed, although
he admits that it scarcely rivals them.[195] His 22 patients were
relieved in 4.4 days as the average, and no complications occurred in
any of them. Benzoic acid is said not to produce the nausea,
depression, or unpleasant head phenomena of salicylic acid, to which it
is closely related in chemical composition.
[Footnote 193: On this subject see Farier-Lagrange's _Essai sur la
Trimethylamine_, Strasbourg, 1870; _Journal de Méd. et de Chirurgie_,
1873, No. 2; _Medico-Chir. Rev._, i., 1873, 497; _Lancet_, ii., 1875,
675; _The Practitioner_, London, i., 1875; _Le Progrès Médicale_, Jan.
10, 1874; _ibid._, Aug. 9, 1879.]
[Footnote 194: _The Brit. Med. Jour._, 1881, p. 1012. See also Tyson,
_Philadelphia Med. Times_, 1879, vol. x. 359.]
[Footnote 195: _Centralb. f. d. Med. Wiss._, 1st May, 1880, quoted in
_Practitioner_, Sept., 1880. See also McEwan's experience, _Brit. Med.
Journ._, i., 1881, 336; F. A. Flint, M.D., _N.Y. Med. Gazette_, 1880.]
Space will not permit of any notice of lemon-juice, perchloride of
iron, the mineral acids, or the blistering treatment. Of this last my
experience enables me to say that it frequently relieves the pains
promptly, but does not at all always protect the heart. In my opinion
it deserves an extended employment in conjunction with early and full
doses of the sodium salicylate. As Andrews has not by any communication
made since the publication of his paper in 1874[196] maintained the
value of the treatment of the disease by an exclusively non-nitrogenous
diet of arrowroot, and as he had then treated but eight cases in that
way, it is hardly necessary to consider it as a method of treatment.
[Footnote 196: _St. Barth. Hospital Reports_, vol. x. 359.]
Having spoken of the treatment of the general disease acute articular
rheumatism, it remains to speak of the treatment of its visceral
manifestations and of some of its more important incidental symptoms
and complications. As the treatment of the various forms of cardiac
inflammation will be given in extenso in the articles specially devoted
to those topics, I will be very brief in my notice of them.
In every case of rheumatic fever it is our primary duty to employ those
measures as early and deftly as possible which in the present state of
knowledge appear to promptly relieve the pyrexia and articular
symptoms, and lessen the tendency to, but do not altogether prevent,
the visceral complications. Such measures have been already said to be
the administration of the salicylates and alkaline salts together in
full doses, and the observance of certain dietetic and hygienic details
to be given hereafter. If, notwithstanding, peri- or endocarditis, or
both, supervene, as it frequently happens, what is to be done? I reply
that even in pericarditis active interference is seldom necessary; the
general treatment previously employed may be continued in the hope that
it may mitigate the cardiac inflammation by reducing the pyrexia and
subduing the polyarthritis, even although it be incapable of directly
controlling the pericardial inflammation. If the pain in pericarditis
be really severe and the heart's action much disturbed, a dozen leeches
may be applied over the heart, and be followed by anodyne fomentations
or hot poultices applied, as Lauder Brunton advised, over several
layers of flannel interposed between the skin and them. Leeching,
however, is seldom needed, a hypodermic injection of morphia generally
sufficing to relieve the pain. Should these measures not relieve the
pain and allay the cardiac excitement, small and repeated doses of
chloral, which Balfour observes "is not more useful as a sedative than
as an antiphlogistic," may be given. If there be, as so frequently
happens, but little pain or cardiac disturbance, there being only a
friction sound revealing the inflammation, the hot poultices or anodyne
fomentations, or even covering the front of the chest with wadding or a
belladonna plaster, which I prefer, will suffice. Should pericardial
effusion ensue, the diet must be improved, and if much {64} debility
exists, the salicylate and alkalies should be stopped, and wine may be
given along with quinine alone or with pretty full doses of muriate of
iron. As the strength returns absorption commonly takes place; but if
it is delayed, either the iodide of potassium or the infusion of
digitalis may be employed along with the quinia; or, if no special
contraindication exist, a pill containing a grain each of blue mass,
digitalis, squill, and quinia may be given three times a day and its
effects carefully watched. Much difference of opinion obtains as to the
value of flying blisters on the præcordia. Although not often required,
they appear to be more useful than iodine applications. In those
comparatively rare instances in which the effusion is abundant and
remains unabsorbed, either because it is largely sero-purulent or
purulent, it is proper to aspirate the pericardial sac, which should
certainly be done if marked signs of cardiac oppression and failure
coexist. Having once hesitated to aspirate in recent rheumatic
pericarditis with copious effusion in a lad, and found a large amount
of pus in the sac after death, I would warn against hesitancy under
such circumstances. Careful employment of the instrument can hardly do
harm if even no large amount of effusion exist.
Active treatment is quite uncalled for, as a rule, in acute rheumatic
endocarditis unattended by pericarditis. If the valvulitis occur
notwithstanding the employment of the anti-rheumatic remedies, it is
very doubtful if we have any others capable of directly controlling
that inflammation. Inasmuch, however, as, owing to the inflamed surface
being in constant contact with the fluid, many of our remedies may be
applied directly to the diseased part, it is well neither to be
dogmatic on the point nor to abandon hope that agents may yet be found
that will prove directly useful. While carefully treating the rheumatic
fever, the main indications remaining to be filled appear to be to
quiet the cardiac excitement and secure as much rest to the inflamed
valves as possible. The alkaline salts, salicine, and the salicylate of
sodium do usually greatly reduce the frequency of the heart, and, pro
tanto, secure rest. The tincture of aconite given hourly, so as to
slacken the heart's speed, is useful in the sthenic stage of endo- and
of pericarditis; and the benefit of absolute rest of the body in bed
and of the joints in splints during the entire course of rheumatic
fever, in preventing cardiac inflammations and in treating them, has
been shown by Sibson.[197] When signs and symptoms of cardiac weakness
arise, whether from the pressure of pericardial effusion or from
myocarditis or any other cause, the employment of salicylates,
alkalies, aconite, and chloral should be at once stopped and alcoholic
stimulants and tonics (strychnia, quinia, iron) and good food should be
freely administered. The most valuable point made of late in the
therapeutics of acute inflammations of the valves is Fothergill's
development of Sibson's principle--viz. that "general quietude for
weeks after an attack of acute endocarditis is indicated," as the
cell-growth in the valve may not be quite over in a less time,[198] and
the work of repair, we may add, not completed. The same principle is
specially applicable in myocarditis.
[Footnote 197: Reynolds's _System of Med._, vol. iv. p. 527, Eng. ed.]
[Footnote 198: _Diseases of Heart, with their Treatment_, 2d Series,
1879, 149.]
The disturbances of the nervous system were divided into those {65}
dependent upon gross organic alterations of the nervous centres and
their envelopes, and those not so related, but which we commonly speak
of as functional. Were it possible generally--which it is not--to
diagnosticate rheumatic meningitis from the merely functional form of
so-called cerebral rheumatism, then its treatment would resolve itself
into a vigorous use of the anti-rheumatic remedies, salicylates,
alkalies, etc., and the active employment of ice and leeches to the
scalp, purgatives, full doses of the iodide and bromide of potassium,
ergot, etc. If, together with the symptoms of that often obscure and
comparatively rare complication of rheumatic fever, ulcerative
endocarditis, there occurred severe headache, delirium, or paralysis,
we might find great difficulty in determining the cause of the cerebral
disturbance, and would naturally vary our measures according as we
suspected meningitis, embolism, or simple functional disturbance, and
the treatment adapted to these several conditions will be found under
their respective heads in this work.
Coming now to the functional disturbances of the nervous centres, which
are the ordinary forms met with in acute articular rheumatism, they may
be divided, for therapeutical reasons, into two groups: (1) Those
unattended by hyperpyrexia, and (2) those preceded, accompanied, or
followed by hyperpyrexia.
(1) When any sign of disturbance of the nervous system, delirium,
restlessness, taciturnity or talkativeness, insomnia or somnolence,
deafness, tremulousness, vacancy, stupor, or what not, occurs in
rheumatism with but a moderate temperature, 101° to 103°, while we
anxiously watch the temperature from hour to hour, prepared to combat
any tendency to hyperthermia the moment it is discovered, we endeavor
to control the cerebral disturbance as in other febrile affections, but
with greater diligence, knowing that in this disease these nervous
symptoms very often precede hyperpyrexia. We persist with the
salicylates to reduce the rheumatic element of the affection, employ
remedies to control the cardiac or pulmonary inflammations which are so
frequent in such circumstances, sustain the general powers by food,
wine, and quinia, if, as frequently happens, there are evidences of
failing strength, and meet any other special indication that may arise.
For example, we procure sleep and allay motor and mental excitement by
opium or chloral and by evaporating lotions or the ice-cap to the head.
We reduce temperature, allay restlessness, preserve the strength, and
promote sleep by lightening the bed-clothes, drying frequently the
entire surface of the body if it is perspiring freely, or by sponging
it with tepid water hourly if dry and hot. We act on the kidneys,
bowels, and if necessary the skin, if from the scantiness of the urine
or other evidence we suspect uræmia. Should these means fail and the
delirium and other symptoms which occur in cerebral rheumatism
continue, and especially should they be severe, it would be, in the
writer's opinion, proper to employ the methods that are now resorted to
when hyperpyrexia accompanies those symptoms; for patients suffering
from cerebro-spinal disturbance or rheumatic fever, although unattended
by hyperthermia, do die if those symptoms continue. Moreover, the
hyperthermia may at any moment supervene; it is itself perhaps as much
a nervous disturbance as delirium, and apt to succeed the latter. It
was in these very cases in which the delirium preceded the hyperpyrexia
that the London committee to be presently mentioned found the highest
{66} mortality. If along with these nervous symptoms the articular pain
or the sweating disappear suddenly, or if the pulse suddenly increase
in frequency without demonstrable increase of cardiac mischief, there
is reason to anticipate the supervention of hyperpyrexia.
(2) When the cerebro-spinal disturbance of rheumatic fever is followed,
preceded, or accompanied by hyperpyrexia, there is one indication for
treatment which dominates all others, and that is the prompt reduction
of the hyperthermia. The terrible danger of this condition in rheumatic
fever is known to all persons who have had much experience of the
disease. Wilson Fox in 1871 had not known a case recover after a
temperature of 106° unless under the use of cold, yet that is not an
alarming temperature in intermittent or relapsing fever, and is often
recovered from in typhoid fever. Thanks to Wilson Fox,[199]
Meding,[200] H. Thompson,[201] H. Weber,[202] I. Andrew,[203] Maurice
Raynaud,[204] Black,[205] Fereol,[206] and many others since, it has
been established that when the hyperthermia is removed by external cold
the nervous disturbances also usually at once disappear or lessen very
much. And thus we are brought to the treatment of the hyperpyrexia of
acute articular rheumatism. On this important topic it will be most
satisfactory and convincing to give some of the conclusions arrived at
respecting hyperpyrexia in acute rheumatism by a committee of the
Clinical Society of London.[207] I will condense some of them.
[Footnote 199: _Treatment of Hyperpyrexia_, 1871, and _Lancet_, ii.,
1871.]
[Footnote 200: _Archiv für Heilkunde_, 1870, xi. 467.]
[Footnote 201: _Brit. Med. Jour._, ii., 1872; _Lancet_, ii., 1872; and
_Clinical Lectures_, 1880.]
[Footnote 202: _Clin. Soc. Transactions_, v. 136.]
[Footnote 203: _St. Bartholomew's Hosp. Repts._, x. 337.]
[Footnote 204: _Journal de Thérap._, No. 22, 1874.]
[Footnote 205: _Gaz. Hebdomad. de Méd. Sci._, 1875.]
[Footnote 206: _Soc. Méd. des Hôpitaux_, 8 Juin, 1877.]
[Footnote 207: _Brit. Med. Jour._, i. 82, 807.]
1. "Cases of hyperpyrexia in acute rheumatism prevail at certain
periods;" "such excess corresponds in a certain degree, but not in
actual proportion, to a similar excessive prevalence of acute
rheumatism generally. The largest number of cases of hyperpyrexia arise
in the spring and summer months, whereas rheumatism is relatively more
common in the autumn and winter." 2. "Whilst very little difference
obtains between the two sexes in regard to proclivity to rheumatism,
the proportion of males to females exhibiting hyperpyrexial
manifestations is 1.8 to 1." (3 omitted.) 4. "The cases of hyperpyrexia
preponderate in first attacks of rheumatic fever." 5. "Hyperpyrexia is
not necessarily accompanied by any visceral complications, but may
itself be fatal. The complications with which it is most frequently
associated are pericarditis and pneumonia." 6. "The mortality of these
cases is very considerable, hyperpyrexia being one of the chief causes
of death in acute rheumatism." 7. "Although present in a certain number
of cases, and these of much value from their prodromal significance,
neither the abrupt disappearance of articular affection, nor the
similarly abrupt cessation of sweating, is an invariable antecedent of
the hyperpyrexial outburst." (8, 9, 10 omitted.) 11. "The post-mortem
examinations in a certain proportion elicited no distinct visceral
lesions, and when present the lesions were not necessarily extensive."
12. "The prompt and early application of cold to the surface is a most
valuable mode of treatment of hyperpyrexia. The chances of its efficacy
are greater the earlier it is had recourse to. The temperature cannot
safely be allowed to rise above 105° F. Failing the most {67} certain
measure--viz. the cold bath--cold may be applied in various ways: by
the application of ice, by cold affusions, ice-bags, wet sheets, and
iced injections."
Whatever differences of opinion may obtain as to the value of cold in
the treatment of the hyperthermia of typhoid fever, there is a
tolerable consensus of opinion that it is our most reliable and
promptest resource in those formidable cases of rheumatic fever
attended with hyperpyrexia, both when alarming delirium and coma
coexist and when they are absent.[208] Space will not allow of details
here in the employment of cold to reduce hyperpyrexia--a subject
discussed elsewhere in this work. Suffice it to say, that besides the
cold bath (70° or 60°) which the committee regards as the most certain,
the tepid bath (96° to 86°) is employed by Fox and regarded as the best
by Andrews; it may be cooled down to 70° by adding ice or cold water to
it (Ziemssen). The cold wet sheet-pack is still thought much of, like
the last, in old and feeble people. Kibbie's method deserves more
attention than it has received. He pours tepid water (95° to 80°) over
the patient's body, covered from the axillæ to the thighs with a wet
sheet and laid upon a cot, through the open canvas of which the water
passes and is caught on a rubber cloth beneath the cot, and conveyed
into a bucket at the foot of the bed.
[Footnote 208: The powerful depressing effects of high temperature on
the human body, and the remarkable opposite influences of a cool
temperature, have been personally experienced by the writer in the last
three days. For two or three days the weather has been very hot, and he
has experienced the usual feeling of exhaustion, incapacity for thought
and action. After a thunderstorm last evening the temperature fell 25°,
and this morning, twelve hours later, he feels vigorous, refreshed, and
capable of intellectual and physical labor. The change is remarkable.]
The existence of polyarthritis, of peri- or endocarditis, of pneumonia
or pleurisy, does not contraindicate the cold bathing. If much weakness
of the heart obtains, it is well to give some wine or brandy before
employing the bath, and perhaps while in it, and the patient should not
be kept in the bath until the temperature reaches the norm, for it
continues to fall for some time after his removal from the bath. If the
temperature fall rapidly 2° to 3° in five or six minutes, remove the
patient from it as soon as the temperature recedes to 102° or 101° F.
If it fall very slowly, the bath may be continued till the temperature
declines to 99.5°, when he should be taken out. Should marked symptoms
of exhaustion or of cyanosis arise, the bathing should be at once
stopped. After it has been found necessary to employ cold in this way,
the thermometer should be used every hour, and if the temperature tend
to rise rapidly again, the diligent application of a succession of
towels wrung out of iced water and applied to the body and limbs, or of
Kibbie's method, may suffice; but should they not, and a temperature of
103° or 104° be rapidly attained again, the cold or tepid bath should
be at once resumed. In severe cases of this kind a liberal
administration of alcohol and liquid food is generally needed, and it
is well to try antipyretic doses of quinia by mouth or rectum, although
they are usually very disappointing in these cases. It is admitted that
cold baths have in a few rare instances caused congestion of the mucous
membrane, pneumonia, pleurisy, and even fatal syncope. This is a reason
for the exercise of care and constant oversight on the part of the
physician, but hardly an excuse for permitting a person to die in
rheumatic hyperpyrexia without affording {68} him at least the chance
of recovery by the use of the cold or tepid bath.
If delirium and deafness supervene during the employment of the
salicylates, it is prudent to suspend their use and take the
temperature every couple of hours, as one cannot feel confident that
hyperpyrexia may not be impending. Both Caton and Carter have found
that the addition of bromohydric acid to the sodium salicylate
mitigated or controlled the tinnitus and deafness produced by full
doses of that salt.
SUMMARY OF TREATMENT OF ACUTE RHEUMATIC POLYARTHRITIS.--As a general
rule, commence at once with a combination of sodium salicylate, say 10
grains, and citrate of potass. gr. xv, every hour for twelve doses,
after which give the citrate alone every two hours during the rest of
the day. Repeat these medicines in the same way daily until the
temperature and pain have subsided, when only half the above quantities
of the drugs are to be given every twenty-four hours for about a week
longer, after which three 15-gr. doses of the salicylate, with a like
quantity of the citrate, are to be administered every day for another
week or ten days, to prevent relapses. It is in this third week that
quinia is most likely to be required, and as a general rule it may be
given with benefit at this period in doses of 2 grains three times a
day between the doses of the salicylate. Should the above dose of
salicylate not relieve the pains sensibly in twenty-four hours,
increase next day the hourly dose to 15 or 20 grains; and if this free
administration of the medicine afford no relief after four or five
days' use, substitute for the salicylate salt the benzoate of ammonia
in 15- to 20-grain doses hourly, continuing the citrate of potassium
and conducting the treatment in the manner first advised. Should the
benzoate likewise fail after four or five days' trial, omit it, and
employ the full alkaline method together with the quinia, of which
about 10 to 15 grains may be given in the day between the doses of the
alkaline salt.
For the local treatment no uniform method is invariably applicable. In
many cases simply painting the joints with iodine daily, or enveloping
them in cotton wool, with or without the addition of belladonna or
laudanum, and securing it by the smooth and gentle pressure of a
flannel roller, proves sufficient. Hot linseed poultices containing a
teaspoonful of nitre or of carbonate of soda often afford relief, and
so does Fuller's lotion, applied to the articulations by means of
spongio-piline, or lint covered with oiled silk. It consists of liq.
opii. sed. fl. ounce j, potass. carb. drachm iv to drachm vj,
glycerinum fl. ounce ij, aqua fl. ounce ix. It must be plentifully
applied. If the articular affection be very severe and not relieved by
the above measures, absolute immobility of the joints, secured by means
of starch and plaster-of-Paris bandages, has been shown to be very
useful, relieving the pain, shortening the duration of the local and
the general disturbance, and protecting neighboring joints from
invasion.[209]
[Footnote 209: See Heubner in _Archiv der Heilkunde_, vol. xii., and
Oehme in _ibid._, vol. xiv., and a striking case in _St. Barth. Hosp.
Reports_, 1876, p. 174, by R. Bridges, M.D.]
We have little experience in this country of ice continuously applied
to the joints until all the symptoms of acute rheumatism have
disappeared (Esmarch and Stromeyer).
Circlets of blistering fluid applied above all the affected joints {69}
simultaneously, as practised especially by Herbert Davies,[210] often
afford prompt relief to the pain, but they do not invariably protect
the heart, in my experience.
[Footnote 210: _London Hospital Reports_, vol. i., 1864, 292.]
The hygienic and dietetic management of acute articular rheumatism
demands careful attention. While the room should be well supplied with
fresh air and sunlight, it should be kept at a uniform temperature and
free from draughts. Feather and other very soft beds should be
prohibited. Many authorities put the patient between heavy blankets,
which I regard as a mistake. The bed-clothing should be light and just
sufficient to keep the patient agreeably warm; the night-gown may be of
thin flannel and the sheets of cotton. The excess of perspiration
should be removed by gentle rubbing with a warm towel at regular
intervals, and the sheets should be changed frequently before they
become almost saturated with the perspiration. Fatigue and exposure of
the patient's person when taking food, attending to his natural calls,
or having his personal or bed-clothing changed should be specially
guarded against.