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man-always a man-with pain in joints ered under the head of diathesis. The usually below his hips, knees possibly in- drug treatment of arthritis deformans volved, but more typically the ankles and is almost useless, that there is room for surfeet. He has pain and tenderness in the gical and orthopedic treatment is made bottoms of his feet and very frequently clear by the fact that, in a recent lecture, tender spots under his heels. He had gon- John B. Murphy spoke two hours and fortyorrhea many years ago but no symptoms five minutes on the surgical side of the since. Many doctors have told him that he treatment of this disease alone. The has chronic gonorrheal rheumatism.” proper surgical or mechanical treatment
It is a striking fact that women do not will be suggested in each individual case have this chronic gonorrheal rheumatism” will depend upon the type of the disease(they have no prostate gland), also that dry, atrophic or hypertrophic and upon the men who have been catheterized years pre- stage of the disease. viously but who have never had gonorrhea, To properly carry out such treatment; have sometimes this so called "chronic gon- indeed, to determine what may be hoped orrheal rheumatism;' and further, none of for in each case, radiographs must be made these cases have gonococci in any secretion, and the actual condition of each joint ascer. even in the prostatic fluid, but all have en- tained. larged and juicy prostates and the prostatic One thing which the medical practitioner fluid contains staphylococci and other com- may do in arthritis defornians is to properly mon organisms.
regulate the diet. Almost all patients with So I have become convinced that these this disease are at first treated for chronic cases are all mierely suffering from absorp- rheumatism and put upon a rigid diet. tion of toxins from prostatic pus, from pros- This is a great mistake as the constitutates infected with pus germs during a tional condition in arthritis deformans is former gonorrhea, or by means of a cathe exactly opposite to that in chronic rheumater. The pus germs live on forever, while tism. So the diet, instead of being regonococci do not, gonorrhea being, in a stricted, should be made as rich in digestmeasure, a self-limited disease. So these ible and nourishing foods as possible. In old cases are found free from gonococci, fact food, fresh air, tonics and much good though gonococci may have been the pion- water, and at times of acute exacerbation, eers in establishing the trouble. Of one the aspirin mixture, and, when deposits thing we may be sure, however: Massage threaten, the iodides, about cover the medithe prostate regularly and the symptoms cal management of a case. Massage is leave. When I say prostatic massage the useful to prevent contractures; heat, word should be prostatic milking.
sweating and bandaging all have places at It is remarkable that so few men know times. Above all the rule should be-vever how to properly express the prostatic fluid stop treatment, even if all symptoms disapfrom the gland. To introdcue the rubber pear, as each exacerbation is more difficult covered index finger into the rectum and to manage than the one preceding. make a sweeping fan-shaped friction mo- Chronic rheumatism and the rheumatic tion over the prostate elicits much pain dia thesis, as well as gout and the gouty and very little fluid, but such is the usual diathesis require the same general treatprocedure. The correct method is to make ment, excepting of course the acute gouty a steady pressure on the gland until the exacerbation. finger has sunken into it surface, as into an The notable condition in both of these edematous spot. Then move the finger diatheses is the retention of some product over and repeat the pressure and keep doing which should be eliminated by the kidneys. this until the surface of the gland has been In gout, the product left by faulty metabcovered several times. The pain is less and olism is known to be uric acid. In the the result is more fluid expressed. I have rheumatic diathesis with recurring attacks frequently had patients remark that pros- of subacute trouble the product retained or tatic massage had never brought a drop over-produced is also supposed to be uric from them and a few minutes later have seen acid. The retained product may be very the treatment done as above outlined, cause complex but when I say uric acid I mean all half a drachm of fluid to pass from the of it whatever it may be. urethra.
In fact, I am inclined to accept chronic Arthritis deformans is not rheumatism, rheumatism and gout, or the rheumatic except in the lay sense of the word and its and gouty diatheses as being the same treatment is almost the exact opposite in thing in different generations. A man may every feature and principle to that of acquire a moderate degree of gout by his chronic rheumatism, which will be consid- own misguided efforts and we call it chronic rheumatism. His son, with the same danger of urates crystallizing before the habits, acquired chronic rheumatism more urine is passed. The most important promptly and more severely. After a few means of elimination are found to be generations heredity takes almost entire through the bowels and through the skin. charge and a son is born who has the dis- The bowels should be kept flushed with ease to live down, not to acquire, and we some alkaline laxative, although at times call his case gout.
a mercurial purge may be indicated. This The one great cause of these diatheses is alkaline purgative theoretically serves the over-eating and especially over-indulgence added purpose of neutralizing uric acid, in proteids. Just so much muscle produc- but I doubt very much if any such effect ing food can be used in the system. The takes place. The flushing effect on the excess can not become fat to any extent, so bowels is a daily necessity in these cases it becomes waste matter.
and relieves the kidneys of overwork. When a rising American leaves off man- Any method of causing a sweat is useful ual labor and outdoor exercise for ease and but when it follows reasonable exercise it comfort or for confining office work, he does is more beneficial than when due to a hot not leave off the outdoor appetite of his bath or cabinet, as the increased metabolyouth. In fact, eating becomes a pastime ism precedes the sweating elimination. and diversion and appetite is stimulated This is why the radioactive hot baths at by alcohol. He cannot possibly use all of certain health resorts are so wonderfully those eggs and steaks which he consumes beneficial to these cases, far superior to as he does not use his muscles and they soon ordinary Turkish or other hot baths. cause more waste products to form than his These supposedly radioactive baths are kidneys can eliminate. When at this stage given at a temperature about that of the almost any exposure will cause neuritis, human body, still, after twenty minutes joint trouble, etc. Later on, when the immersion in such a bath the patient's temgouty stage has been reached or inherited perature has risen two degrees on an averthe metabolism is so perverted that an ex- age. No stronger evidence of increased cess of uric acid is manufactured in the metabolism could be offered than this rise system, even without over-eating, though of temperature above that of the bath. The made worse by indulgence. Certain acids, sweat which follows must necessarily be as that of strawberry or tomato, seem to
far more eliminative than a sweat proprovoke this perversion of metabolism. The duced merely by external heat. principal treatment of these conditions is High frequency currents and electrical plain to every patient even; cut off sup- auto-condensation will frequently be found plies and eliminate waste products. That useful in increasing metabolism and lowersounds very simple but, to most patients, ing blood pressure. In fact a large field the first step means to take away from seems to present itself in the use of electhem everything which they like best. tricity,' the X-ray and radioactive subVery little success in treatment will be ac- stances of which we will know much more complished, however, unless this is done. in a few years.
The first aid to elimination is exercise. In closing, I must apologize for having This cannot always be carried out suffi- had the temerity to read a twenty-minute ciently to aid metabolism. Frequently the paper on a subject on which one could lecsmall amount of exercise taken only has the ture every day for a week. If this is all bad effect of increasing the appetite. But, too condensed for mental digestion blame when possible, exercise should be pushed your honorable secretary, he brought this to the reasonable limit, all circumstances being considered.
DISCUSSION. Elimination through the kidneys cannot DR. WILLIAM W. DUKE, Kansas City: The subbe increased very much. Usually these ject of the papers this morning is certainly a most organs are doing all that they can do.
important one. Rheumatism is responsible for a Drinking copiously of good, pure water
large percentage of the chronic invalids and arthritis
is responsible for many of the pains and aches of is one most dependable means of stimulat. old age. A distinction should be made between aring the kidney secretion but in many in- thritis and rheumatism. The term arthritis signistances the increased flow is offset by a low
fies an iniammation of the joints while rheumatism
is the name of a systemic disease one symptom of specific gravity and the total of urinary which is an arthritis. Rheumatism is a systemic solids is not increased. The 'only drug disease in the same respect that typhoid aud pneupromising to increase the elimination of monia are. I shall confine my part of the discusuric acid is atophan, which may be given
sion to acute articular rheumatism. It would be dif
ficult to take up the entire subject of arthritis in the n five or ten grain doses. If combined
limited time at my disposal. with bicarbonate of soda there will be less The older writers noted the striking relationship
between the incidence of chorea, endocarditis and rheumatism. Many of the later writers have considered these conditions different manifestations of one disease. Other lesions which are considered sometimes rheumatic in origin are iritis, a cerebral condition called cerebral rheumatism, myocarditis, inflammation of the serous membranes (pericarditis, pleuritis, and even peritonitis) also snbcutaneous fibrous nodules, a few cases of nephritis, and certain skin manifestations, especially erytheina nodosum. Some writers think some types of purpura, and even urticaria are rheumatic in origin.
Dr. Wootton differs with some of our best writers when he says that acute articular rheumatism is not a clinical entity. I will admit that uncertainty exists in the minds of many observers as to whether rheumatism is caused by one specific organism or by several. The vast majority agree however, that there is an acute polyarthritis called rheumatism which differs entirely in its pathology from the various forms of infectious arthritis, arthritis deformans, etc. The salient characteristics of the arthrtis of rheumatism is that it nearly always involves many joints-it migrates quickly from joint to joint
-is always a simple synovitis and pariarticular inflammation, aud finally when it leaves a joint, it leaves it in practically a normal state-at most only a few fibrous adhesions remain. Some observers claim that the rheumaticinflammation may cause erosion of cartilage, but they are certainly in the min. ority. Other diseases may simulate rheumatism but that is true of most diseases, and certainly does not speak against the view that rheumatism is a disease entity. Poynton and Payne have isolated in blood culture from a great proportion of their cases of rheumatism an organismcalled by them the diplococcus rheumaticus. They have obtained it also from the urine and from many of what they considered rheumatic lesions. The organism has been demonstrated by these observers, and others, in rheumatic joints, endocardial tissues, in various of the serous membranes and in rheumatic nodules. Poynton and Payne further succeeded in producing a number of these lesions by injection of the organism in animals. They and others have produced endoearditis both benign and ulcerative, joint swelling similar to those of rheumatism, inflammation of serous membranes; and they have also produced jerky movements in monkeys which were thought analogous to those of chorea in humans. The only objection which might be made against this work is the enormous amount of material which had to be used to get results. They had to inject the growlh from three or four cultures. Smaller doses were inert. I wrote Dr. Welch and asked his opinion regarding the work of Poynton and Payne. He replied that he did not believe a specific micrococcusrheumaticus had been conclusively demonstrated, but that the question was an open one and was by no means settled adversely to Poynton and Payne's claims. These men, by the way, were not the original discoverers of this diplococcus rheumaticus It was obtained in blood culture by Mantle, an English clinician, in 1877 from several cases of rheumatism. He was unable however, to reproduce the disease in animals, due he thinks to the fact that he did not use large enough doses of the virus.
In regard to the portal of entry, rheumatism en ters by way of the throat in the great majority of cases. The lesion may be simply diffuse redness, a follicular tonsillitis, or a superficial ulcerative condition that could be mistaken for diphtheria. Rheumatism differs from the other forms of arthritis iu this respect: The primary focus of infection of the other forms may be any suppuration, especially the chronic mild ones. It may be infected pasal sinuses, middle ear disease, pyorrhea alveolaris, infection of
the respiratory or intestinal tract or genito-urinary organs.
The diagnosis of acute articular rheumatism is usually simple. Rheumatism is called an acute mi. gratory polyarthritis. It is nearly always acute, nearly always a polyarthritis and nearly always migratory. Chronic rheumatism is a term often used to cover almost any chronic joint disease. The existence of a chronic form of real articular rheumatism is doubted by many of our best observers. McCrae says he has never observed a case and failed to find a single case in the Johns Hopkins Hospital records which he could consider as such. Certainly, if it exists it is excessively rare.
DR. C. B. HARDIN, Kansas City: I have enjoyed these papers on rheumatism very much, but in the five minutes allotted me I cannot say much about the subject. There were several points that impressed me, and first that rheumatism is a self-lim. ited disease, as used to be taught, but now it is any. thing else but that. Secondly, I want to ask a ques. tion in regard to the line of treatment, whether it should be a mixed treatment or whether we are to rely very largely on the use of the salicylates. As to rendering 'the blood alkaline, it is a question with me whether that ought to be done or not. We know that rheumatism is considered an infection due to some germ or germs, and those germs are said to thrive best in alkaline media, and not in acids as above or neutral conditions. The gyneic surgeon takes advantage of this when he realizes that the vaginal secretion is acid, keeping out or destroying the germs that inhabit the vagina preventing it or them from going up into the uterus and the more vulnerable tissues above. That struck me very for cibly. I would like the gentleman in closing that part of the discussion relating to treatment to allude to that point.
Massage was spoken of, but I do not know whether I ought to allude to this illustration or not. I was called to see a case of acute rheumatism, attended with fever and all the acute symptoms of the disease. The patient was having great pain. He employed an osteopath, who went to see him every day for awhile, and who massaged the joints, and of course you can imagine the result. The fellow almost screamed with pain in his presence and the method of treatment. He sent for me afterwards and I put him on the salicylates, and in twenty-four hours or less I had him comparatively comfortable.
Endocarditis, pericarditis, and possibly myocardial degeneration are not accidents in rheumatism. They are incidental to rheumatism, and in my opinion belong to the disease. We should not look upon them as mere accidents. Where a child with rheumatic fever has an endocarditis you can look upon it as belonging to the disease and not accidental. I be. lieve if a careful analysis were made it would be determined that this was not an accidental result, but a part of the disease; in other words, a terminal involvement. It ought to be included in the rheumatic picture itself.
DR. WOODSON Moss, Columbia (closing): I think the question of the etiology of rheumatism has been pretty well threshed over. The evidence is all in and each one has mentally registered his verdict. I feel that the reading and discussion of these papers have been of great interest and profit to us all. I know that I have gained a great deal of very valuable information.
DR. HORWITZ, St. Louis (closing): From the papers that have been read it has been conclusively shown that arthritis and rheumatism have the same origin and should be considered systemic in character. I believe Dr. Wootton is not justified in draw.
a sharp line between the two, acknowledging the acetic acid ester of salicylic acid, commonly rheumatism is a systemic disease and that ar- called aspirin, to any of the other salicylates. I did is is not. I do not believe any such sharp line not mention the use of pyramidon, but will state istinction can be made.
now that I consider it very useful as a pain reliever. R. W. T. Wootton, Hot Springs (closing): I do Have also had excellent effects from atophan, espeleny that the so-called diplococcus rheumaticus cially in gout and neuritis. I do not think it neccause acute arthritis in many cases, but I do essary to make an attempt to render the blood more ; that it is the only organism that causes arthri- alkaline. The alkalies formerly used gave good efpericarditis or endocarditis. Most any virulent fects but chiefly because they were also purgatives. nism will cause the same condition in a joint as One speaker has mentioned massage. We would liplococcus rheumaticus.
certainly not expect any good results from the adR. E. H. MARTIN, Hot Springs (closing): Dr. ministration of massage to an acutely inflamed joint. dingasks if the salicylates are useful in acute Any acute inflammation contraindicates massage. I ular rheumatism. I consider them the most im- did not include heart lesions or the lesion of the pleura ant part of the treatment next to relieving the or meninges in my paper for two reasons: First, I e, for weshould, in every case, try to obliterate had very little time to cover the subject, and secfocus of infection. As stated, I prefer the use of ond, I was trying to approach the subject from the 'salicylate of acetic acid," or in other words, viewpoint of the layman.
I believe if I should die
Cold, dead and dumb to all the world contains
Life would come gladly back along my veins.
Not knowing what the poor clod chanced to be,
And throb again—warm, tender, true to thee.
Youreyes should drop some warm tears of regret
To prove death could not make my love forget.
And you should long once more my face to see,
Led by their beacon blaze, fell full on me.
I would as soon expect to see the sun
As thee unworth the worship thou hast won.
Like one who, with the grape within his grasp,
Out from his careless and unheeding clasp.
That gems life's petals in its hours of dusk.
-Mary Ashley Townsend.
Kansas City Academy of Medicine
Meeting every Saturday evening at the Coates House
Censor, C. B. Francisco, M. D.
Treasurer, C. B. Hardin, M. D.
DISCUSSION OF THE TREATMENT OF very low class of people, in which neither
SYPHILIS, AND THE ADMINISTRATION mercury or salvarsan, jodine or general OF 150 INJECTIONS OF SALVARSAN.* tonic treatment will be of any effect in FRANK M. DenSLOW, M.D., Kansas City, Mo.
staying the process. We have had only
three of such cases at the old City Hospital, Clinical Lecturer on Genito-Urinary Diseases. University Medical College: Staff Atterdant in Genito-Urinary all of which died. Two of these cases were Diseases at Ord City Hospital.
marked by extensive ulcerations of the This paper is not intended to be a scien- vulvo-anal region, and the other of the legs. tific resume of the subject of salvarsan, as Many tertiary syphilides, gummata, etc., regards its therapeutic efficiency, nor as re- have been much benefited by salvarsan. gards its utility from laboratory standards, However, we have no illusions about one but is rather intended to awaken discussion or two injections of salvarsan curing the upon a subject which is of great interest to disease. We always give mercury almost all of us from a clinical standpoint, and as though the other had not been taken. give us each the results of other's experi. To my mind, the principal use of salvarsan ence.
is for the purpose of getting a rapid effect At the time the subject was taken up in upon the symptoms of the disease, to reduce this society previously, there were not many the infective period as represented by who had had experience with the remedy, chancre and mucus patches, and to get rid and those few not to the present extent. in the shortest possible time, of a disfigur.
No attempt will be made by me to give ing eruption. All of this we know it will complete case histories and records, because do, but if it lulls the patient with second. I do not have them. Most of these injec- ary syphilis into a false sense of security, tions were made at the old City Hospital, it has done him harm. All of us have seen where the idea in giving them has been to recurrences after a single dose of salvarsan. get the patients out of the hospital and out what a considerable number of successive of the City's charge as soon as possible. doses may do, I do not know. I have Some of them were given in the G-U Dis- never given more than three doses to any pensary of the University Medical College, one patient, the last two of them being and a number in private practice.
always in the absence of symptoms, except In practically all the cases given in the the adenopathy, which does not readily City hospital, the Wassermann test was disappear under salvarsan any more than positive.
by the old style of treatment. This applies also to the private cases. A. In tertiary syphilis we go right on with test was done even in the cases where the the iodides, and mercury as well. As to clinical history was clear, for the moral the effect of the newer treatment in pre effect upon the patient, so that he would be venting locomotor ataxia and general par willing to continue treatment in the latent alysis of the insane, we have no knowledge stage.
as yet. The whole thing is too new. So As to the therapeutic effect, the imme- far I have never heard of a case of tabe diate result in almost all cases has been or paresis developing, where the remedy gratifying. In two cases of syphilitic my has been used in the secondary period. elitis there was very little response. In Probably in ten years from now we shall one of the cases the patient regained tem. have heard of many of them. Since Noguchi porary use of the sphincters. We have had has demonstrated the spirocheta pallida three cases of malignant syphilis in the brains of paretics, it may be that the which the injection did no good. salvarsan, if it be the spirillocide its frienu Whether or not other cause beside claim it to be, will go far to prevent th the syphilis militates in these malig- so-called parasyphilitic developments. nant cases against the recovery of the pa. It seems to me, based upon practical tients, I do not know. I only know that servation, that the logical method of treat there will occasionally be encountered a ment today, of cases seen in the early say case, usually (in my experience), among a ondary period when they usually com