Willis Webster Grube.

A compendium of practical medicine for the use of students and practitioners of medicine online

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sons under forty years are exempt from this affection. Paralysis
occurs late. The patient has a tendency to run forward and has
a fixed, staring countenance. In senile trembling the head is
chiefly affected and there is no paresis of muscles, no stiffness, no
deformity of the extremities, and no impulse to run forward.
Alcoholic, lead and mercurial trembling are readily diagnosti-
cated by the previous history (Bartholow, Flint and Loomis).

Treatment. — Xo plan of treatment is satisfactory. Hyoscy-
amine, according to Charcot, is the best remedy to moderate the
trembling. Gelsemium is useful. The chloride of gold and so-
dium, corrosive sublimate in small doses, nitrate of silver, and
the lactophosphate of lime with arsenic may be tried. The gal-
vanic current may be tried (Bartholow and Loomis).


Called also rickets, rachitismus and osteomalacia, is a con-
stitutional disease of the first years of life, characterized by a
disorder of nutrition in which the growth of the bones is irregu-
lar, calcification imperfect, and deformities ensue (Bartholow).

Causes. — Rickets is a common result of faulty diet and of
anti-hygienic surroundings, and is therefore frequent among the
poor of cities, and especially in families who dwell in crowded
tenement-houses. It is more common in the great cities of
England and Europe than in this country. Acute disease and
troublesome dentition predispose to it. It is more apt to occur
in children of rachitic, syphilitic or phthisical parents. The off-
sj>ring of consaiiguinious marriages, of those too old, or of the
feeble and cachectic, are, as a rule, rickety. The rickety consti-
tution may also be inherited. Of the exciting causes, the most
common is the use of food not sufficiently nutritive, or, if nutri-
tious, not suited to the age and digestive powers of the child.
Thin and poor breast-milk and artificial food of poor quality are


common causes of rickets. The presence of lactic acid in the
intestinal canal of the infant may produce rickets according to
some authorities. The disease is rare before the fourth and after
the seventh year of life. Children of well-to-do families are also
liable to rickets (Bartholow, Loomis and J. L. Smith).

Symptoms. — Usually gastro- intestinal disturbances are the
earliest symptoms of rickets. There may be vomiting, and the
stools are frequent, pasty and offensive. The stools are light in
color, because of the absence of bile, and have an acid reaction.
The appetite is poor. The child wastes and grows dull, listless
and peevish. Pains about the joints are complained of. The
anterior fontanelle remains open.

Profuse perspirations of the head, neck, and upper part of
the chest, appear chiefly while the child is asleep, but at the same
time the abdomen and extremities are dry and hot. The child
kicks off the covers from its legs. There seems to be tenderness
of the whole body, and the rickety child cries out when it is
taken up, or moved, or pressed on. It is languid, its counten-
ance wearied, depressed, and aged, the face grows broad and
square, the hair is thin, dry, and dead, the muscles are wasted,
and flabby, the head sinks between the shoulders, and the abdo-
men is swollen and protuberant. Now the extremities of the long
bones swell and have a knobby appearance, and the bone bends
readily. The child may be knock-kneed, or have bow-legs.
Curvature of the spine also takes place. The lower jaw is short-
ened, so that the upper teeth overlap the lower. The teeth appear'
late. Rachitic children are usually pigeon-breasted, and there is
often marked deformity of the pelvis. The ribs, being softened,
yield to the atmospheric pressure, thus projecting the sternum
forward. The head of a rickety child appears larger than that of
a healthy child of the same age, is flat on top, and the forehead
is large and square. The limbs of the child are short in propor-
tion to the trunk. Rachitic children are anaemic and very sensi-
tive to changes of temperature. As the osseous changes go on
emaciation goes on at the same rate, the abdomen enlarges still
more, the muscles waste and grow weaker, there is less and less
disposition to voluntary exertion, the perspirations are more free,
the thirst increases, the bowels become more deranged, the stools


fetid, and the food passes unchanged. All rickety children do not
emaciate. Persons who were rachitic in infancy frequently be-
come very strong as they reach adult life (Bartholow, Loomis
and J. L. Smith),

Differential Diagnosis. — The only disease with which rickets
in its early stage may be confounded is inherited syphilis.
Rickets does not appear, as does syphilis, during the first days
of life. The "snuffles" and cutaneous lesions do not belong to
rickets; the sweats about the head, the osseous changes, the
enlargement of the spleen and liver, the weakness of the legs,
the rims around the cranial bones, the large, lax joints, and the
gastro-intestinal disturbances are symptoms of rickets which dis-
tinguish it from any other disease (Bartholow and Loomis).

Prognosis. — Is usually favorable, provided no serious com-
plication arises. The complications of rickets are bronchitis,
pneumonia, enteritis, laryngismus stridulus, convulsions, difficult
dentition, diarrhoea, and chronic hydrocephalus (Loomis).

Treatment. — Good air, warm clothing, daily bathing, and a
nutritious diet are essential. Children kept too long at the
breast often become rickety, and should be weaned at once.
Good cow's milk, diluted by one-third to one-fourth of lime-
water is the most suitable aliment. Scraped raw beef, with a
small amount of wine, often produces marked improvement.
Pepsin with bismuth may be given for the vomiting and diar-
rhoea. Pepsin with diluted muriatic acid is also useful. Cod-
liver oil should be taken as early and in as large doses as the
child can digest. Beef tea may be given. Rachitic children
should not sleep on feather beds or high pillows. The perspira-
tions may be relieved by sponging with vinegar and water. The
following formula will be found useful in most cases:

|fc Olei morrhme 3iv.

Aqua; calcis

Syrupi calcis lactophosphatis — aaoij. — M.

Of this, one teaspoonful should be given four or five times
daily to an infant of one year (Bartholow, Loomis aud J. L.



Is a constitutional disease characterized by certain local
manifestations seated in the articulations and the fibrous tissues
in other parts (Flint).

Varieties. — I. Acute articular rheumatism. II. Sub- acute
articular rheumatism. III. Chronic articular rheumatism. IV.
Arthritis deformans. V. Muscular rheumatism, " Myalgia "
(Loomis). Acute articular rheumatism frequently called rheu-
matic fever and. polyarthritis rheumatica is the variety charac-
terized by fever, inflammation of the joints occurring in succes-
sion and by a tendency to attack the peri- and endocardium.

Causes. — It is more frequent in men than in women because
men are more exposed to the influences producing it. Protracted
stay in damp apartments, lying between damp sheets all night,
exposure of the body to cold and wet, when in a heated and per-
spiring state act only as an exciting cause. A special predisposi-
tion is requisite. This predisposition or diathesis may be con-
genital and inherited or it maybe acquired. There is an hered-
itary tendency in about thirty per cent, of cases. It occurs
mostly between fifteen and thirty years of age. It is rare in old
age. The seasons of greatest prevalence are winter and spring.
Some claim that an excess of sulphur or lactic acid in the blood
will produce rheumatism if the vice of constitution exists. Erysip-
elas, dysentery, scarlatina, gonorrhoea, syphilis, pregnancy, scrof-
ula, phthisis and cancerous affections seem to act as exciting
causes (Bartholow, Flint and Loomis).

Symptoms. — In the majority of cases, acute articular rheuma-
tism begins with a sudden attack at night. In some cases the
pyrexia precedes the local manifestations for a few hours to one
or two days. Before the attack patients often complain of mus-
cular soreness, of a good deal of pain, stiffness and soreness of
certain joints, of loss of appetite, coated tongue and constipa-
tion. The development of the disease is denoted by an affection
of one or more of the larger joints. The local symptoms are
pain, tenderness, increased heat, swelling, and redness of the
skin. Pain is especially excited by movements of the affected
joints, or by jarring the bed, or by pressure over the joints.


Swelling is most apparent in the knee, wrist, elbow, ankle, and
smaller joints of the hands and feet, and is due to an effusion
into the synovial cavity and surrounding tissues. The redness is
due to an erythema. In some cases several joints are affected,
but in other cases a single joint. The most characteristic feature
of acute rheumatism is its tendency to migrate from one joint to
another. Rheumatism illustrates the law of parallelism in that
corresponding joints are often affected together. In an analysis
of 21 cases, Flint found but a single violation of this law. This
disease, therefore, is eminently one of the bilateral or symmetri-
cal diseases. The joints most frequently affected are the aukle
and knee; next the shoulder, elbow and wrist; then the hip and
fingers, and finally the spine, the toes and the lower jaw. Acute
articular rheumatism is always accompanied by more or less
pyrexia. The axillary temperature in different cases varies be-
tween 102° and 110° F. The pulse rarely exceeds 100 per
minute. Sweating is a symptom more or less prominent, occur-
ring especially at night. The sweat emits a notably sour odor.
In connection with profuse sweating, sudamina or miliary vesicles
frequently appear on the neck and trunk. Urticaria, erythema
aud herpes labialis sometimes occur in the course of the disease.
The appetite is lost, thirst is urgent, the tongue is coated, the
saliva is acid, usually the bowels are constipated, and the urine
is diminished. There is sleeplessness. Endocarditis occurs in
some cases of rheumatism. The inflammation, as a rule, affects
the membrane situated upon the mitral valve. Pericarditis occurs
less frequently. It is convenient to speak of these affections as
complications, but, properly speaking, they are to be reckoned
among the local manifestations of the disease. They rarely occur
in patients beyond forty. Other rare complications are purulent
meningitis, cerebral embolism, uraemia, insauity, bronchitis,
pneumonia, peritonitis, nephritis, myocarditis, phlebitis, suppur-
ative arthritis, erysipelas and pyaemia. In a small number of
cases of acute rheumatism, important symptoms develop which
are described under the names of cerebral rheumatism and rheu-
matic hyperpyrexia. In these cases, there are very high fever,
delirium, muscular twitchings, stupor, face cyanosed, etc. These
symptoms seem to be referable to some profound infection or in-


toxication which, acts upon the thermic and other nervous cen-
tres. The disease ends by self -limitation. The duration of acute
articular rheumatism is three weeks to thirty days (Bartholow,
Flint and Loomis).

Differential Diagnosis. — Acute rheumatism may be mistaken
for gout, pycemia, synovitis, or simple acute arthritis, urethral
rheumatism, and hysterical joint. Gout attacks the small and
rheumatism the large joints. In gout the fever is lower, and the
duration of the attack shorter than in rheumatism. Sweats and
cardiac mischief distinguish rheumatism from gout. In gout the
attack comes on at night in the great toe joint; there is a history
of high living, and an excess of uric acid in the blood; not so in
rheumatism. Gout is rare before thirty-five, while acute rheu-
matism is a disease of early adult life. Tophi never form in
rheumatism, but are always present late in gout. In pyamiia
there are recurring chills, sickly, sweet breath, slow development,
jaundice, multiple abscesses, etc. Synovitis or acute arthritis is
distinguished by its persistence in one joint, by the absence of
sweats, of constitutional disturbance and of cardiac lesions, and
by the graver local symptoms. Urethral or gonorrhoea} rheuma-
tism attacks one joint, usually the ankle or wrist, does not mi-
grate, is slower to recover, is unaccompanied by fever, and is
coincident with a urethral discharge. Hysterical joint is without
swelling or change of temperature, and is only sensitive when the
patient's attention is fixed on it (Bartholow, Flint and Loomis).

Prognosis. — This disease is rarely fatal. The rule is that no
crippling of the joints follows the acute attack. The worst
legacy acute rheumatism leaves is a crippled valvular apparatus
in the heart. Some authorities say that seventy-five pei cent, of
all cases of rheumatic fever are accompanied by cardiac inflam-
mations, others say five per cent. The complications — pericar-
ditis, endocarditis and embolism make the disease serious. Ul-
cerative endocarditis is a grave sequel of the disease, giving rise
to fatal pysemia. A strange sequel of rheumatic fever is chorea
(Flint and Loomis).

Treatment. — Rheumatic patients should have good hygienic
surroundings. The temperature of the apartment should range
from 68° to 70° F.; all draughts should be avoided, and the


patient should be clothed in flannel and covered with flannel
sheets. The diet should be milk and seltzer-water, beef-tea and
broths. Animal food and alcoholic stimulants should not be
given during the active period of the disease.

External Applications. — Cold, by means of ice-bags to the
joints, has been strongly recommended. Friction with chloro-
form and the tincture of aconite is a favorite plan with some.
"Hot-packs" by means of flannel, or bathing the joints in warm
laudanum and then covering them with oiled silk, is always
grateful to the patient. Ethyl chloride or ether may be rubbed
over the affected joints. Loomis is of the opinion that the blis-
ter-treatment is no better than simply surrounding the joints with
cotton -batting and oiled silk. But Dr. Greenhow finds that the
blister-treatment is quite as successful as the treatment by sali-
cylates, and open to less objection. The blistering- plaster should
be applied about the inflamed joint, but not on it. Blisters re-
lieve the pain remarkably, change the reaction of the urine from
acid to neutral or alkaline, and prevent complications. Blisters
may be utilized in all forms of the disease and combined with
other plans of treatment.

Internal Medication. — Kheumatism is the most unmanageable
of all diseases so far as remedies are concerned. Garrod thinks
colored water is about as potent as anything. He claims that
rheumatic fever is a self-limited disease. The alkaline treatment
is the treatment in which alkalies play an important part. Two
drachms of the bicarbonate of either potassium or sodium may
be given in a state of effervescence by means of an ounce of
lemon juice, or a half drachm of citric acid in four ounces of
water every three or four hours. If the urine is alkaline at the
end of twenty -four hours the quantity of alkali is diminished
one -half. If the urine continues alkaline at the end of forty -
eight hours, three drachms of alkali only are given on the third
day. If the alkalinity of the urine persists, on the fourth day
three grains of quinine with a half drachm of potassium bi-
carbonate may be given three times daily. Cathartics may be
given as required. The alkaline treatment relieves the pain, seems
to shorten the duration, lessens the violence of the disease and
prevents heart complications. The average duration of the cases


thus treated is put by Dr. Fuller at eleven clays. Of 439 cases
subjected to this plan there was not a fatal case, and only about
two per cent, of cardiac complications. Loomis thinks that if
long continued the alkalies do positive harm. The alkaline treat-
ment is particularly applicable to the obese, florid, but flabby
drinkers of malt liquors. The iron treatments applicable to the
pale, delicate anaemic young subject attacked with acute rheu-
matism, in whom the alkalies are too depressing. A half drachm
of the tincture of the chloride of iron to six ounces of water, may
be taken through a glass tube every four hours.

The salicylic or salicylate treatment is most applicable to the
vigorous, able-bodied subjects of the rheumatic diathesis. Sali-
cin, salicylate of soda and salicylic acid, to be effective, must be
given in sufficient quantity to lower the temperature — a half-
drachm of salicylate of sodium every four hours, until the pulse
and temperature decline, may be taken as the standard. Al-
though relief follows the administration of these remedies in
two or three days, yet the tendency to relapses, heart depression
and irritability of the stomach is very great. The salicylate
treatment does not prevent the heart complications. The best
results are obtained by the combination of the salicylate and the
alkaline treatment. Loomis prefers salol to salicylic acid. He
seldom uses the alkaline, or salicylate treatment, but extols anti-
pyrine as the most efficient drug. Flint gives antipyrine in
fifteen grain closes hourly, but does not give more than two
drachms in twenty-four hours. For the intense hyperpyrexia in
some cases, large doses of quinine may be given and cold spong-
ing practiced. Dr. Kinnicutt gives 10 to 15 minims of the oil of
winter green every two hours until eight doses have been taken.
DaCosta has reported 30 cases treated with the bromide of am-
monium in doses of 15 to 20 grains every three hours (Bartho-
low, Flint and Loomis).

Subacute Articular Rheumatism. — Is usually a sequel of the
acute; it is attended by slight if any fever; the pain in joints is
not severe, except on motion; swelling and redness are slight
and usually limited to one or two large joints. It may last six
weeks or even four months. There is always anaemia. The


treatment is a milk diet, iron and cod -liver oil, a warm climate,
and heat to the affected joints (Loomis).


Is an affection of the articulations characterized by pain and
stiffness, with some swelling, occurring chiefly after middle life,
and influenced by atmospheric changes (Bartholow).

Causes. — The chronic may succeed to the acute, or the case
may be chronic from the first. It is a disease of adult and ad-
vanced life. Bad hygienic surroundings, exposure to wet and
cold, sudden atmospherical changes, and a residence in dark and
damp dwellings predispose to it. It is often hereditary (Bartho-
low and Loomis).

Symptoms. — The affection remains fixed in certain joints;
that is, it does not shift from joint to joint, as in cases of acute
rheumatism. There is aching and constant pain in one or more
of the larger joints. The affected joints are tender, painful to
the touch, sometimes swollen, and their movements restrained.
There is no fever. The aching and deep-seated pains are often
worse at night. When it is the result of exposure, heat will give
a grateful sense of relief; when a rheumatic diathesis exists, dry
cold is better. Old people with rheumatic joints are great
u weather prophets" often being able to foretell the coming of a
storm. In the morning, on rising, the joints are stiff, their
movements slow, rigid and jerking, so that dressing is accomp-
lished with difficulty; but use renders them limber and supple.
Movements of the joints may cause more or less creaking like
rusty machinery (Bartholow, Flint and Loomis).

Differential Diagnosis. — Chronic rheumatism may be mistaken
for rheumatoid arthritis, or arthritis deformans. In the latter
occur anatomical changes, dislocations, and distortions which do
not belong to the history of chronic rheumatism. Arthritis de-
formans is a steadily progressive disease, one joint after another
being involved and never recovered from. In chronic rheuma-
tism the large joints are mainly involved; in arthritis the small
joints are usually first involved, then the large (Loomis).

Prognosis. — -Chronic rheumatism never affects the duration
of life. It may persist throughout life ( Loomis ).


Treatment. — Chronic rheumatism is benefited most by local
treatment, such as blisters, iodine, belladonna, acpnite, opium
and chloroform liniments. If there is but little pain in the
joints, ammonia and turpentine liniments are of service. Thick
flannels should always be worn about the joints. Sponging the
joints with hot water will relieve the pain and stiffness in some
cases. Warm baths, the Turkish or Russian baths, with local
douches, are often highly useful. Many of the hot saline springs
for bathing have acquired a great reputation in the treatment of
this form of rheumatism, cures being effected in cases that had
resisted all other methods of treatment. The best results are
obtained from the baths of the Hot Springs of Arkansas, the
warm and hot springs of Virginia, the sulphurous waters of
Kentucky and Saratoga, the Michigan springs, and St. Cather-
ine's of Canada. Mud-baths are also employed on a large scale,
for the relief of rheumatism and affections of the skin, in certain
parts of Germany. Frictions of the affected parts with cod-liver
oil are efficacious. The method of friction and movements,
Tvnown as massage, is probably the best of the local means of
treatment. Galvanism has been found serviceable. The posi-
tive pole should be placed over the principal nerve-bundles
above, and the negative pole brushed over the joint-region. The
.electrical treatment must be kept up for a long time.

Internal Medication.- — Tonics such as iron, quinine, and
strychnine should be employed. Cod-liver oil, according to
Loomis, is the most useful of all internal remedies, and should
be given for many months. Cod-liver oil should be given with
a little ether to assist its digestion. A course of iodide of potas-
sium often renders important service, if given many months.
Muriate of ammonia may absorb deposits about the joints but it
must be given for a long time. Bartholow has had excellent re-
sults from the bromide of lithium. Colchicum, arsenic, bichlor-
ide of mercury, guaiacum, oils of turpentine and cajeput, com-
bined with sulphur have been recommended. The diet must be
highly nutritious and absolutely non- stimulating. The patient
should reside in a dry, warm climate (Bartholow, Flint and



Called also arthritis deformans, rheumatic gout, rheumatic
aHhritis, nodosity of the joints, dry arthritis, etc., is a chronic
inflammation of the joints, without fever and without suppura-
tion, progressive, and causing enlargement and deformity of
various articulations (Bartholow).

Causes. — It may occur at any age, but in the majority of
cases patients are in middle life. Women are more liable to it
than men. The smaller joints are most often involved in women;
the larger in men. Damp dwellings, poor food, and mental de-
pression are powerful predisposing causes. It is not an inherited
disease. It occurs in the poorer classes of society, as a rule, and
among those who suffer from hardships, exposure, and depriva-
tions. Garrod holds that it may have its origin in the tubercular
diathesis. A state of the nerve-centres is invoked to account for
this disease (Bartholow, Flint and Loomis).

Symptoms. — The disease is usually from the first and during
its course, sub-acute. A feature of the disease is its progressive
character. There is usually no constitutional disturbance. The
affected joints are painful, especially on motion. A characteris-
tic deformity of the fingers is a lateral deflection in the ulnar
direction. In the progress of the disease the anatomical changes
lead to permanent extension or flexion of parts, subluxations,
dislocations, nodulations and notable distortions. The soft parts
about the joints usually atrophy. Early in the disease a friction
crepitus is heard as the articular surfaces are rubbed upon each
other. The skin is dry and harsh, and there is a great acidity of
the stomach. In the worst cases all the joints are fixed in bony
ankylosis (Bartholow, Flint and Loomis).

Differential Diagnosis. — Arthritis deformansm&y be confound-

Online LibraryWillis Webster GrubeA compendium of practical medicine for the use of students and practitioners of medicine → online text (page 39 of 57)