nursing them have had the disease in their hands or hands and wrists;
exacerbations have recurred during subsequent lactations, and yet the
disease has either become arrested or progressed very slowly and at
long intervals. It is admitted, however, that these are all exceptional
cases, and that the tendency both of polyarticular and of the
monoarticular forms is to progress, and, either steadily or at
intervals and by recurring attacks, to permanently deform the joints
and impair their movements. Even under these circumstances, however,
the patients may suffer little pain unless when forcible movements of
the articulations are attempted.
On the other hand, while the disease cannot be regarded as curable
under the employment of drugs, very much can frequently be done,
especially in the polyarticular form, to relieve the suffering and to
retard, if not arrest, the progress of the disease, and even to restore
sometimes very considerably the functions of the joints. Neither of
these forms of rheumatoid arthritis can be said to be dangerous to
life, and they often exist ten or twenty years and more without
seriously injuring the general health. Heberden's nodosities are
incurable, but they are little more than deformities.
TREATMENT.--The treatment of rheumatoid arthritis is, as a rule,
disappointing, and perhaps no affection requires more perseverence and
self-reliance on the part of the physician or more hopeful resolution
on that of the patient. Our first duty is to make an exhaustive search
as to the probable cause of the disease, as its removal is an important
step in the treatment of the affection, although such search is
frequently futile, and many of the alleged causes may, after all, be
mere antecedents or coincidences. However, inasmuch as the pathology of
the disease is very obscure, any abnormal condition of organ or
function that may be discovered should receive strict and prompt
attention, lest it should, either through disturbed innervation or
malassimilation or impaired nutrition or defective excretion, be the
predisposing or exciting cause of the disease. In women the most
careful inquiry should be made into the state of the ovario-uterine
organs and functions, and the least departure from their norm should be
at once treated. Deficient, excessive, or painful menstruation,
leucorrhoea, ovarian irritations, or pain, even displacements of the
uterus or ovary, should be corrected as soon as possible. Repeated
pregnancy and prolonged lactation, recurring mental anxiety and
physical fatigue, defects of diet, want of food, of sunlight, and of
good air, residence in damp dwellings, occupations involving exposure
to cold and wet, are conditions supplying important indications which
too often are {97} beyond the control of the physician, although they
peremptorily require his attention. The general form is often met with
in anæmic persons and in those of impaired health and vigor, and
probably very rarely occurs under opposite circumstances; and there is
a consensus of opinion that a lowering system of treatment is
contraindicated in rheumatoid arthritis.
Having efficiently set about correcting or removing these various
predisposing or determining causes of the disease, we next direct our
care to the disease itself. The remedies which had been found most
useful in rheumatoid arthritis before the introduction of salicylic
acid were cod-liver oil, quinia, iodine, iron, arsenic, and various
mineral waters, employed either externally or internally, usually in
both ways. Judging from my own late experience and from the results
obtained by Sée[257] and other French physicians, as communicated by
Jules Compagnon,[258] sodium salicylate, given in sufficient doses,
promises to be more generally useful in the more acute forms or in the
actively inflammatory periods and exacerbations of the disease than any
of those agents. Including Sée's cases, Compagnon has related 17
examples of rheumatoid arthritis, most of them of the general
progressive form, in which great improvement as regards pain,
stiffness, swelling, and even deformity, followed promptly the
employment of that salt, even after the failure of other remedies. It
proved signally useful recently in a rebellious chronic case of my own.
Pollock has lately published an instance in which 5 grains of
salicylate of quinia three times a day were in three or four days
followed by great relief.[259] The testimony already given of Dr. J. T.
Eskridge as to the great value of this salt in chronic rheumatism will
be held by some to be corroborative of its value in rheumatoid
arthritis. It is hardly necessary to say that it often fails in this
intractable disease, but it has frequently relieved the pain and
swelling and arrested the progress of it, at least for the time, even
when alkalies, iodine, arsenic, baths, etc. had failed.
[Footnote 257: _Bullétin de l'Académie de Méd._, Paris, t. v., 2d
Serie, 1877.]
[Footnote 258: _De l'Utilite du Salicylate de Soude dans le Traitement
du Rheumatisme_, par Jules Compagnon, Paris, 1880.]
[Footnote 259: _The Lancet_, ii., 1882, 141.]
It is probable that less than 45 grains per diem of the sodium salt is
of little value in even the most chronic forms, and that the quantity
requires to be increased in proportion as the febrile symptoms are
active, so that a drachm and a half or two drachms may need to be
administered in the day to some persons. It should be given in divided
doses at intervals of two hours, and, what is of primary importance, it
should be continued for a long time, even after much improvement has
resulted, and should be resorted to from time to time, especially
during recurrences of the pain, heat, or swelling. It is of
consequence, especially in elderly patients, to ascertain that the
medicine is being promptly eliminated by the kidneys and to watch its
effect upon the heart. The administration along with it of a little old
rye whiskey or brandy will sometimes be necessary in feeble people. In
those rather common cases in which the skin is inactive and perhaps
harsh the salicylate often improves that important organ of oxidation
and elimination, and should it not do so the addition of the ammonium
carbonate may be tried, especially in feeble persons with weak hearts.
{98} Moreover, the other drugs which sometimes prove serviceable in
this disease may be given at the same time or alternately with the
salicylate, or instead of it if it is not found to be of use or is not
tolerated. In chronic cases a prolonged course of cod-liver oil, alone
or along with malt extract, often seems to be of real service,
especially when nutrition is much impaired or when the patient is the
subject of acquired or inherited struma. Iodide of potassium, in
combination with quinia or other tonic, will often prove signally
useful in chronic cases unaccompanied by pyrexia, in which the pains
are worst at night. It should be first tried in moderate doses (5 to 8
grains), and be continued for a long time with occasional
intermissions, and before discarding it from disappointment--which
often arises--15- to 20-grain doses may be given tentatively for a
short period. Milk or coffee or Vichy water are good vehicles for its
administration. Whether free iodine in the form of the tincture, so
highly spoken of by Laségue,[260] acts as well or better than the
iodide of potassium is doubtful. He gave it at meals, in doses
progressively increased from 10 drops to 5 or 6 grammes twice a day, in
sherry or sweetened water, and persevered with it for a long period.
Garrod has had many restorations to health in severe forms of this
disease from the persevering employment of the syrup of the iodide of
iron. The iron in these preparations may deserve as much commendation
as the iodine, for it has often proved signally useful in this disease,
not alone on account of the anæmia which so frequently attends it, but
through its beneficial influence upon the nutritive functions and the
circulation.
[Footnote 260: _Arch. Gén. de Méd._, 1856.]
The usual rules regulating the employment of iron are to be observed,
and the condition of the digestive organs will demand special attention
during its employment. Although the influence of arsenic upon
rheumatoid arthritis is not uniform, yet as it sometimes proves really
useful[261] it should be tried. Like iron, it may prove beneficial in
several ways--by improving the quality of the blood, promoting the
circulation in the superficial layers of the skin, or exerting some
influence upon either the nerve-centres or perhaps upon the vaso-motor
nerves of the cutaneous or articular tissues. The last-mentioned
suggestion is favored by the circumstance noted by Charcot--viz. that
the first effects of arsenic in nodular rheumatism are often
intensification of the articular pains, and sometimes the production of
redness and swelling where they did not exist before. That author found
arsenic without effect or injurious in very inveterate cases and when
the disease had appeared at an advanced age. Five to ten minims of
Fowler's solution, or of the solution of the arseniate of sodium, which
is perhaps less irritating than the former, should be given immediately
after meals, and its effects upon the gastric and hepatic functions
carefully watched. De Mussy has highly recommended arsenical baths
(drachm ss-ij of arseniate of soda to 30 gallons of water), but as the
arsenic is not absorbed by the unbroken skin, any improvement which may
follow its employment is probably owing to the temperature of the bath
or the bath itself.
[Footnote 261: As to the value of arsenic in rheumatoid arthritis, see
Bardsley's _Medical Reports_, London, 1807; Begbie, _Edin. Med. and
Surg. Jour._, 1858; Fuller, _lib. cit._, p. 362; Garrod, _lib. cit._,
3d ed., p. 534; Guéneau de Mussy, _Bull. de Thérapeutique_, t. lxvii.,
1864, p. 24; Charcot, _lib. cit._, p. 222.]
A similar remark has been made respecting the value of the various {99}
thermal mineral baths, natural and artificial, so much employed in this
disease.[262] It is neither the nature nor proportion of their mineral
ingredients, but the degree of temperature, which constitutes the
essential point in the action of a bath. This, if true, explains the
almost equal reputation of the many varieties of thermal mineral
springs in the treatment of rheumatoid arthritis and chronic
rheumatism. It is this that permits the physician to promise the poor
patient as much benefit from the employment of hot baths of simple
water as of those of New Zealand, Plombières, or Arkansas.
[Footnote 262: Vide Niemeyer, _Text-Book Pract. Med._, N.Y., 1867, p.
488; _Traitement du Rheum. par les bains à haute temperature_, par Ch.
Aug. Bouther, Paris, 1878.]
The time for a resort to hot baths in rheumatoid arthritis is when the
very violent pains have subsided sufficiently to allow of their
employment; and while they may be hopefully used in the most chronic
and advanced cases, the earlier they are employed the more curative
they are. The temperature of these hot baths need not, as a rule,
exceed 95 to 100° F., although some authorities approve of raising the
temperature to 110° or 112° while the patient is in the water. A series
of twenty to thirty such baths, taken every second day for ten to
twenty minutes, is sufficient for one trial, and often effects very
great improvement in the disease. The aggravation or return of pain in
the joints which often follows the employment of warm baths will cease
after the fifth or sixth bath. Garrod's experience of the Turkish bath
is not favorable; it very often does much mischief by causing debility,
and its excessive use has induced rheumatoid arthritis in persons
previously free from the disease.
Now, while it may be true that simple hot-water baths employed at home
are as good as mineral thermal baths taken at their source, it is
generally admitted that it is best to send persons who can afford the
expense to the springs themselves, where they may drink the waters as
well as employ them externally, and at the same time secure all the
advantages arising from change of habits, scene, and climate, from
restriction to a proper diet, and from the systematic employment of the
waters and baths under the direction of persons experienced in their
administration, etc. No reliable rules can be laid down for the
selection of the mineral waters best adapted to each case: the stronger
alkaline waters perhaps had better be used with great care, such as
those of Carlsbad, Vichy, Mont Doré, Weisbaden, and after a course of
thermal mineral baths at such places as Aix-les-Bains, Wildbad, Bath,
Aix-la-Chapelle, etc., Garrod advises resort to some place where the
air is bracing and the waters tonic or chalybeate, as Buxton, Spa,
Schwalbach, or St. Moritz. In this country good results are often
obtained at the Hot Springs of Arkansas and the Hot Sulphur and the
Lithia Springs of Virginia. The use internally and in the form of hot
baths of the mineral springs of Saratoga, of Michigan, of the Licks of
Kentucky, and of California, of St. Leon and St. Catherine's (Canada),
is frequently very beneficial. In the selection of the mineral waters
to be drunk, and of the temperature and other qualities of the baths to
be employed, careful attention must be paid to the condition of the
functions of the skin, liver, kidneys, and nervous system; but space
cannot be afforded here for the consideration of this extensive topic.
Moreover, it occasionally happens that after failure of {100} sulphur
or alkaline baths some other form may succeed, as the vapor or hot-air,
or tepid or very hot-water bath. If decided benefit follow the first
series of baths, recourse should be had from time to time to a fresh
series, even for several years, in obstinate cases. Mud and peat baths
are much valued in Germany, although they do not always agree with
weakly or aged people.
The local treatment is of equal importance with the general, and it is
not unfrequently more effective in restoring the functions of the
articulations. In that rare variety, acute rheumatoid arthritis,
attended with much pain and heat in the joints, perfect rest in bed is
called for, together with other measures adapted to subdue the
inflammation and allay the pain. Compresses wet with warm water,
rendered anodyne by the addition of laudanum or belladonna, or both,
and covered with oiled silk, suit some cases--light linseed poultices,
applied moderately warm and extending considerably beyond the limits of
the articulation and covered with gutta-percha or oiled silk, in
others. As the pain and local heat subside, the tincture of iodine may
be applied extensively, or blistering-fluid over limited areas above
and below the affected joints, but not on them until the inflammation
has very much abated and is becoming chronic. These simple methods
should be employed assiduously and be aided by appliances to secure
actual rest of the inflamed joints. In the chronic variety complete
rest is not needed unless during the acute exacerbations, but the
movements should be at first somewhat restrained and be regulated by
the effects produced. But the severe pain experienced during the
movements must be borne; it will subside promptly. Decided increase of
pain and heat in the part, lasting many hours, would indicate more
reserve in the use of the joints. It is frequently very difficult to
determine when and to what extent movement may be permitted in this
disease. No fixed rule can be laid down of universal application, but
it may be stated that in proportion as the local disease becomes
indolent and inactive may pressure and active movements of the joints
be resorted to, for they then have a beneficial influence in preventing
stiffness, contraction, and deformity. Indeed, in my opinion it is not
wise to delay these movements long even in subacute cases. The editor
of this work has especially insisted upon the importance of systematic
daily movements of the affected joints as the most essential part of
the treatment,[263] "combined with thorough massage of all the muscles
whose functional activity is impeded and impaired."
[Footnote 263: "Some Practical Remarks on Chronic Rheumatism," by Wm.
Pepper, M.D., _Archives of Medicine_, Oct., 1880.]
The abiding chronic inflammation indicated by local heat, swelling, and
inflammation of the affected tissues may be variously treated. The
joints may be thoroughly fomented with tolerably hot water or by means
of the local vapor bath for half an hour, morning and night, and then
be gently rubbed for ten or fifteen minutes with iodine or weak
mercurial ointment or with the compound camphor or acetic turpentine
liniment, or, if these are too stimulating, with some bland oil, such
as cod-liver or neats' foot or cocoa oil, after which should be applied
hot-water compresses or linseed poultices or a wrap of soft cotton wool
covered with oiled silk and secured by an elastic, moderately tight
roller. If these means prove inefficient and the inflammatory process
grow more {101} indolent, counter-irritants may be conjoined with or
substituted for them. Small fly blisters or strong iodine paint may be
applied close to the joints, or the ordinary iodine tincture may be
brushed over them, or the above ointments or liniments and one of the
bland oils may be more forcibly rubbed in. The prolonged rubbing of
these stiff, swollen joints with oil is not valued as much as it
deserves.
Compression of the thickened tissues by means of a thick envelope of
cotton wool and thin flannel or rubber bandage sometimes acts very
well, probably by reducing the amount of blood and interfering with
cell-growth or promoting cell-degeneration. Hot sand-baths to the
affected joints are sometimes useful.
These several measures should be perseveringly applied, and in
proportion as chronicity prevails the active and passive movements of
the articulations and massage of the muscles and adjacent tissues
should be daily and efficiently practised.
Electricity will often be found an important adjuvant in this as well
as in an earlier stage, not only in improving the nutrition of the
muscles, but in promoting absorption, allaying pain, and subduing
excitability of the peripheral structures, removing muscular
contractions, and probably modifying the local inflammatory processes.
It appears also in some cases to improve the general health. The
constant current is generally the most useful, and should have an
intensity of about ten to fifteen milliampères, and be applied daily
for ten or fifteen minutes. The positive pole, terminating in a large
flat moistened sponge, is applied to the spinal origin of the brachial
or lumbar plexus, according as the superior or inferior members suffer,
while the negative pole is immersed in a vessel of warm salt water in
which the hands or feet are placed. Some apply the negative electrode
to the joints and the positive to the limb higher up.[264] The faradic
current may also be employed on account of its action upon the muscles
and small vessels. In the advanced stage attended with marked
thickening of the articular and periarticular tissues, with
contractions of the muscles and greater or less impairment of movement,
the above measures are still our chief resources; but they may be
employed more vigorously. We have little fear now of lighting up
inflammation; we indeed desire to excite a more active circulation in
the part with a view of removing the congested state of the capillaries
and venules, so favorable to the development of fibroid growths. In
this stage especially vigorous active and passive movements of the
affected joints, and massage of the muscles which move them, and
gymnastics, are imperatively needed, and it is sometimes almost
marvellous what an amount of mobility and usefulness may thereby be
restored to apparently helplessly crippled and deformed articulations
and members. Persons who have not walked for years are frequently so
much improved as to be able to leave their sofa or bed, and with or
without crutches or mechanical aids walk about, while their abiding
pains depart, and this notwithstanding the permanent deformity of the
articular surfaces. (For the various mechanical appliances that are
sometimes necessary in this advanced stage works upon surgery may be
consulted.)
[Footnote 264: Homolle, _lib. cit._, p. 710.]
The hygienic measures to be observed are probably very much the {102}
same as those indicated in the article upon simple chronic articular
rheumatism--some of them at least--and are such as may be inferred from
a review of the exciting causes of rheumatoid arthritis. Be it
remembered also that acute and chronic articular rheumatism appear
amongst the causes of that disease. We are hardly justified in
promising arrest of the disease on removal to a warm, dry, and even
climate; yet wealthy patients need not be dissuaded from trying the
experiment. The use of flannel underclothing and the employment of
tepid or even moderately cool baths, followed by the use of the
flesh-brush or rough towel, are important means of protecting persons
predisposed to this disease. The ordinary hygienic laws adapted to
maintain a healthy state of all the functions, mental as well as
physical, are to be observed, for in this disease the influence of the
mind over the body is shown by the frequency with which rheumatoid
arthritis follows closely upon mental shocks, worry, etc.
The diet, it is generally admitted, should be of a nutritious
character, yet plain and digestible, and, unless specially required to
meet certain indications, should not include heavy wines or fermented
liquors. However, Garrod affirms that uncomplicated rheumatoid
arthritis is not aggravated by the use of porter, ale, or sound wines;
and his rule is to give sufficient of these alcoholic beverages to
support the tone of the whole system, but not enough to excite the
circulation and thereby produce subsequent reaction.
Finally, the above system of treatment must be persisted in year by
year with the object of securing arrest when cure has not been
effected.
Gonorrhoeal Rheumatism, or Gonorrhoeal Arthritis.
SYNONYMS.--Arthrite ou Arthropathie blennorrhagique,
Tripper-rheumatismus, Gonocele, Urethral Rheumatism, Urethral
Synovitis.
ETIOLOGY.--As its name implies, the cause, par excellence, of the
disease is gonorrhoea, as was perhaps first indicated by Selle[265] and
Swediaur,[266] although, no doubt, an affection apparently identical is
rarely observed associated with non-contagious urethral discharge and
with the urethral irritation incident to catheterism and to stricture.
I have seen it associated with a simple mucous urethral discharge in a
man of gouty habit, married and free from the suspicion of specific
infection. Such discharge has been attributed to gouty irritation, to
dietetic and venereal excesses, and to the contact of non-specific
vaginal secretion; and such origin is well established. More than one
observer has noticed a susceptibility to urethritis on the part of
persons who have had gonorrhoeal rheumatism. A gouty taint is
undoubtedly often present in urethral rheumatism. These non-gonorrhoeal
cases require more close investigation than they have received.[267]
Fournier has not met with them.[268]
[Footnote 265: Chr. Th. Selle, _Medicina Clinica, oder Handbuch der
Medicin_, Berlin, 1781.]
[Footnote 266: Swediaur, _London Med. Gaz._, 1781.]
[Footnote 267: See Elliotson, "Non-contagious Urethral Rheum.," _Med.
Times_, i. 60, p. 613.]
[Footnote 268: Fournier, _Nouv. Dict. de Méd. et de Chir._, t. v. p.
228.]
The stage of the gonorrhoea at which the articular affection may appear
varies very much. It frequently sets in from the sixth to the sixteenth
day of the discharge; it is common enough between the third and sixth
or twelfth weeks, and may be delayed as late as the twelfth month.
There {103} is no constant relation between the severity of the
urethral inflammation and the frequency with which, or the time at
which, the articular symptoms arise; and these, once established,
appear to be largely independent of the state of the urethra. On the
advent of the joint affection the discharge usually continues as it
was, although it often abates somewhat. Fresh attacks of gonorrhoea,
even when very mild, often develop new invasions of the articular
affection, as though an idiosyncrasy existed.