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tense inflammation attacks one joint alone, or disproportionately to other joints; cases of rheumatoid affections associated with or resulting from certain specific diseases; and cases of serious visceral complications; then the salicylates are, so far as I know, unsuccessful.
It is held by the apostles of the salicyl treatment, that its employment diminishes the tendency to heart-disease.
The same consequence has been attributed by their advocates to most kinds of treatment which have been practiced with alleged success. This is a subject which it is extremely difficult to investigate statistically; partly because patients never come under treatment at the onset of their malady ; partly because a very large proportion of patients (either in consequence of some further attack of rheumatism, or because it has already arisen in the course of their present illness) already present the evidences of heart disease, when the medical man is called to their assistance; and partly because it is generally difficult or impossible to determine in cases where old heart-disease is present, whether or not a fresh attack of rheumatism is attended with renewal of cardiac inflammation. There is no doubt, I believe, that the tendency to the occurrence of heart-disease is greatest at the beginning of an attack of rheumatic fever, and that this tendency diminishes as the disease goes
There is no doubt, however, that it may develop at any time during the progress of an acute attack. Of course the effect of medicines cannot be retrospective, but assuming that we have a drug which is competent to arrest the rheumatism, and that it is administered effectively before the heart has become implicated, it is obvious that the heart must share in the general benefit, and that the liability to heart-disease in such cases must be lessened. If, then, the salicyl treatment is specific against rheumatism, as I believe it is, it must, pro tanto, be specific against the componant parts of the disease, and therefore against its cardiac factor. Again, it has been largely asserted, by those who freely acknowledge the striking influence of the salicyl compounds over acute rheumatism, that this influence is not so much curative as it is a forcible repression of the disease, which, as soon as the salicyl treatment is discontinued, breaks out with all its original violence, and, in support of this view, it is pointed out that rheumatic patients thus treated are largely liable to relapses, and that the total duration of their illness is not materially, if at all, curtailed. It must be acknowledged that relapses are not uncommon; but relapses are not uncommon in acute rheumatism under other forms of treatment, or under no treatment at all. Neither are relapses uncommon in other diseases which are acknowledged to be amenable to treatment by specific remedies.
* The tendency to relapse manifested by rheumatic fever under salicyl treatment is scarcely, therefore, an argument against the specific influence of the medicine. But the question may be looked at from another side. There has been, and there is, a strong tendency to judge of the effects of the salicylates by their effects upon the temperature, to assume that, when the temperature has become normal, no further benefit can be expected from them, and therefore at once either to discontinue the drugs, or to give them in diminished quantities. This procedure has been determined in no inconsiderable degree by the fact of certain unpleasant symptoms being usually induced by the heroic use of salicylates, which the medical attendant is generally anxious to mitigate. I have no doubt, indeed, that the relapses (certainly not unfrequently observed in connection with the employment of salicylates) are due mainly to this cause, and that they would cease to a large extent if it only came to be fully recognized that salicylates are efficacious not simply by reducing temperature, but by their curative influence over rheumatism, and that they ought not to be discontinued, or even materially reduced in quantity, as soon as the temperature falls.
The last point on which I shall remark is the question of the injurious influence of salicylates on the patients who are treated by them.
That these drugs, given in large repeated doses, cause toxic effects, just as quinine does under similar circumstances, is manifested every day. As a general rule, the patients become deaf, and have noises in their cars; occasionally, delirium supervenes; and occasionally also albumen in small quantities appears in the urine, which possibly may be due to the effects of the medicines, but I have never witnessed any consequence of a really alarming character, and certainly never any permanent mischief. I must acknowledge that I have always diminished the doses if delirium has come It is stated that patients become debilitated under the use of the salicylates, and that, moreover, it is necessary to regulate the diet carefully for some time after apparent cure. I confess I am not disposed to acquiesce in these statements, I do not think that any special debility follows the employment of the salicylates; and I never hesitate to treat, in respect to food and stimulants, convalescents from rheumatism just as I treat convalescents from other inflammatory diseases.
TREATMENT OF ACUTE RHEUMATISM.
By W. R. THOMAS, M. D.
[The following is a part of Dr. Thomas's article on the subject introduced by Dr. Bristowe. — British Medical Journal, Vo. 1286.]
In practice I generally find that we have at least three distinct varieties of rheumatism : 1, the sthenic ; 2, the asthenic ; 3, that variety caused and preceded by other diseases, as gonorrhoea, scarlet fever, etc.
The first kind I have generally found among the well-to-do classes; sometimes among the poorer. The patient, perhaps a commercial traveller or merchant, has always been exceedingly well, and until lately has enjoyed very good health, For some monthis he has suffered from dyspeptic and hepatic derangements : his urine has generally been very high colored, and a large amount of sediment has been noticed daily in it. He has complained of frequent headache, backache, and aching of the limbs. He is florid, and probably very stout, and has found that he could not go through the same amount of work as formerly. Evidently, he has caten and drank more than his body has been able to use and burn updaily; and the several secreting organs, having had too much work thrown on them for a considerable time, are not now able to perform their functions properly.
I shall not deal with the pathology of rheumatism at all; but in this patient there is a tendency to inflammation of certain tissues, and to the accompanying fever. He now sleeps in a damp bed, or catches cold in some way, and now comes on the attack. These are cases where salicylic acid, salicylate of soda, and the bicarbonate of potash are beneficial. Of the two, I am inclined to think that I have seen more benefit derived from the salicylate than from the bicarbonate; but I frequently begin with the salicylate and then go on with the potash. Ittention to little details we all find in rheumatism, as in all other complaints, of great importance; för instance, covering the whole of the chest with a layer of cotton wadding has often. I am sure, prevented an attack of pericarditis from coming on, and I have found a night-shirt of very thin wool very useful, as these patients: perspiring much, are very apt to catch cold: in fact, I now recommend all my rheumatic patients to wear it regularly, and many have been very thankful for the advice. With regard to the joints, I have found wrapping
the affected bones in cotton wool all that is, as a rule, necessary ; but when pain has been very excruciating, hot fomentations, with solution of belladonna sprinkled on the flannel next to the skin, have given relief. For pericarditis, my patients have generally seemed to be relieved by turpentine-stupes, followed by linseed poultices; but, unless it seems to be severe, I think it advisable not to take away the cotton wadding, nor to apply anything else, for I feel sure that the less these patients are exposed the better. If possible I avoid giving anything to procure sleep, but, when obliged to do so, I find our old friend Dover's powder the best. These patients generally require something to act on their chylopoietic viscera ; and I must say that I find nothing equal to five grains of pilula hydrargyri, followed by haustus albus, which draught has often to be repeated. As to diet, there is nothing better for them than milk; and when the fever begins to subside we can afford to be more generous. The asthenic patient is thin, pale and weak to begin with, from
or other; perhaps an over-worked or over-anxious young man who, in his desire to get on in the world, has always neglected himself, and has taken his meals (and of them but little) irregularly; or a young mother with one or two children, living on little else than tea. These patients have the same local signs and the same fever as the other patient had; but although there is the same tendency to inflammation of certain tissues, and the same fever, the tendency has, I believe, been produced by different causes entirely; and to obviate this tendency or to remove the cause, we must, I think, adopt a very different mode of general treatment from what we do in the other class. These patients require plenty of support from the beginning, and we can not give anything better than milk to begin with. Soon this patient will require beef-tea and other foods. As an internal remedy, I think we have none to cqual quinine given from the beginning. Occasionally we may have to give other remedies when called for, but quinine is the remedy on which we have to depend; and later on, I invariably find that the addition of iron is beneficial. The same local treatment is required in these cases as in the other. As aperients, colocynth and aloes are preferable to the mercurial and haustus albus.
Of course, the treatment of rheumatism following other diseases will be different, as such diseases will have to be taken into consideration.
THE INTERNATIONAL MEDICAL CONGRESS. --At the last International Medical Congress, which convened at Copenhagen in '84, a committee of gentlemen from the American Medical Association, in behalf of the “medical profession of the United States " invited the Congress to hold its next meeting in Washington. The invitation was accepted, and Washington was the place fixed for the meeting of '87. The same resolution which appointed “conferred upon the same committee authority to add to its members and exercise all the powers of a committee of arrangements for effecting the preliminary organization of the proposed Congress" (Dr. Davis, in “ Journal of the A. M. A.").
There has been no little fault found with the work of this Committee.
It appears that the Code Question has entered into the appointments, and since the American Association has taken the affair in hand, the New Code men have been given but a poor show'.
The little petty quarrels which not unfrequently appear in sucli affairs have been very much magnified by the view across the ocean, so that many foreigners are expressing grave alarm about the success of the meeting. There is really no cause for this alarm. The natural good sense of the members of the committee on arrangements will surely not allow any local question of professional ethics to play any part in the organization of the International Medical Congress, which is a body having for its central idea the advancement of pure science.
The rules which we print elsewhere would seem to indicate that the committee takes 10 narrow view of its duties. Let us wait until the work is finished before we find too much faut. In the mcan time the profession abroad may rest assured that the American management of the Congress of 1887 will do nothing that is not consistent with the dignity of the profession.
CONSANGUINEOUS MARRIAGES. —Dr. Chas. F. Withington, in the Boston Med. and Surg: Jour., Aug. 27th, gives a tabulated list of