THE TREATMENT OF RHEUMATISM,

761 to notice. In the first place the organ contains no in the second place it may contain a very large number of foreign bodies of the most diverse description, such as wood, coal, bone, fasces, hair, and the like ; and, thirdly, ecchymoses of varying size are commonly present. The intestines are empty and retracted and signs of commencing nephritis are usually present. The urine contains albumin and sugar in some 50 per cent. of the cases. The other lesions that are found, such as petechial hmmorrmges in the pleura and under the pericardium, are to be looked upon rather as lesions produced by the asphyxia, which is the common mode of death, than as intrinsic lesions dependent on rabies. The greatest stress is usually laid by veterinarians on the results of the examination of the stomach in cases of suspected rabies, but the mere presence of foreign bodies and even of fasces in the stomach is most untrustworthy evidence of the disease. No conclusion should be drawn as to the probable presence of rabies unless together with the presence of foreign bodies in the stomach there is absence of food and unless ecchymoses are present. In man post-mortem, signs are also not very marked and very often a number of those actually found are dependent on the mode of death, as, for instance, the acute emphysema that has been described, which is probably dependent on the dyspncea, and the death from asphyxia. In the nervous system the blood-vessels are found to be injected, petechial haemorrhages are not uncommon, and patches of softening have been described in the cord and medulla ; the nerves are also hyperasmic, the salivary glands are congested, and petechial haemorrhages are also found in the mucous membrane of the stomach. Slight nephritis has been already

points food;

described.

In the rabbit the most important post-mortem signs are the congestion and ecchymoses of the mucous membrane of the stomach and intestine. THE EXPERIMENTAL METHOD

DIAGNOSIS OF RABIES. A fragment of medulla or some other part of the central nervous system should be taken from the suspected case and placed in pure glycerine. After being in this from two to three days the fragment of the medulla should be pounded in a sterilised mortar with some sterilised salt solution or bouillon, and an emulsion of it so made should be filtered through sterile muslin and a small quantity of it introduced into a syringe sterilised by boiling. The inoculations should be made either into the anterior chamber of the eye or subdurally, the latter is preferable owing to the fact I mentioned in my first lecture that by this means there is a greater certainty of communicating the disease. Inoculation into the eye or intravenously, or even subcutaneously, may be successful, but there is not the same certainty as there is in the subdural method. The aqueous humour was recommended more especially in cases where the material was suspected of being contaminated with other organisms with the idea that if the eyeball suppurated it could be removed, and at the same time the virus of rabies would have had the opportunity of infecting the nervous system through the optic nerve. So that at one time it was not uncommon to inoculate into the aqueous humour if the suspected material arrived in a putrid state. This procedure, however, is unnecessary, as in many cases brains have arrived at the Brown Institution in the hot weather more or less decomposed, and the inoculation of this decomposed cerebral material subdurally has not been followed by any septic complications. So that in all my observations the subdural method of inoculation was used. If rabies be present the symptoms usually declare themselves from 12 to 19 days after the inoculation, but it is important to remember that they may be delayed for as long as 40 days and that therefore even after inoculation one cannot exclude rabies until a period of something like six weeks has elapsed. This, however, is unusual. There is no difficulty in the diagnosis of experimental rabies if attention be paid to the point that the palsy in the rabbit is accompanied by clonic spasms, and the only difficulties that present themselves in the diagnosis of rabies experimentally lie in the fact that sometimes the brain injected is contaminated with other organisms, such as those of septicaemia, and so the inoculated animals die within two or three days of the inoculation, or else, as in the case quoted in my first lecture, advanced decomposition in the material injected prevents the manifestation of the activity of the virus of rabies. I will conclude my lectures with drawing attention to the incidence of rabies in this country during the last few OF

I

years. In the year 1892 there were 38 cases of suspected rabies reported to the Board of Agriculture. In 1893 there were 93. in 1894 248, in 1895 672, in 1896 438, in 1897 151, and in 1893 17, so that in the years 1894, 1895, and 1896 there was a very severe outbreak of rabies in this country. In 1895 there were 45 suspected cases in London, in 1896 128, in 1897 19, and in 1898 one. At the Brown Institution I investigated in 1896 168 cases of suspected rabies and proved the existence of the disease in 113 cases. In 1897 there were 64 suspected cases and 25 real cases ; in 1898 there were 17 suspected cases ; and in 1899 there were 10 suspected cases, but none of them proved to be cases of rabies. It was, therefore, proved that out of a total of 259 cases of suspected rabies examined in the last four years rabies existed in 138, that is to say, in 53 per cent. of the cases. The experimental method is of the greatest value in providing accurate statistics of the incidence of the disease, but, as I mentioned in my last lecture, it is not so useful for the purpose of determining whether an individual bitten by an animal suspected of rabies should or should not undergo the Pasteur treatment owing to the fact that so long a period-at least from 12 to 19 days-must elapse before a conclusive answer can be given, and because in some cases the incubation period in the rabbit may be prolonged to a length equal to that of the usual incubation period in man-namely, six weeks.

THE TREATMENT OF

RHEUMATISM,

WITH SPECIAL REFERENCE TO PROPHYLAXIS AND ITS CARDIAC COMPLICATIONS.1

BY WILLIAM

EWART, M.D. CANTAB., F.R.C.P. LOND.,

SENIOR PHYSICIAN TO ST. GEORGE’S HOSPITAL AND TO THE BELGEAVE HOSPITAL FOR CHILDREN.

[IN his opening remarks Dr. Ewart compared rheumatism and phthisis in respect of their preventibility, discussed statistics of the prevalence and mortality of rheumatic fever, chiefly as observed in Scandinavia, and made a brief allusion to the subject of cardiac complications. He then proceeded to

consider]

THE INFECTIVE THEORY AND THE ARGUMENTS IN ITS SUPPORT. The ’meteorological arg1lment.-Newsholmepoints out that rheumatic fever shares with several specific febrile diseases a greater prevalence in winter and spring, and with a some of them (enteric fever, scarlet fever, erysipelas, &c.) marked association with a deficient rainfall, the effects of which in lowering the ground water would gradually develop in the subsoil conditions of temperature and dryness favouring the growth of any assumed telluric contagium, whilst a high ground water never accompanies an excessive

prevalence. A strong argument is also derived from the observation that in England a relatively high temperature of the air is favourable to an increase of rheumatic fever, and that in London its great epidemics occur only when the mean temperature of the soil is exceptionally high—i.e., over 50° F., particularly if it has been thus high for two or more years in succession. The bacteriology.-The existence of a specific organism awaits further demonstration. The doubts entertained as to the truly rheumatic character of so-called acute rheumatism in the lower animals detract from the value of experimentations in corpore vili. Organisms have been described in man by various observers to which Newsholme refers.3 Whilst 1 An introduction to the debate of the Chelsea Clinical Society on March 13th, 1900. 2 Milroy Lectures on the Natural History and Affinities of Rheumatic Fever, a Study in Epidemiology. Cf. THE LANCET, March 9th and

16th, 1895. 3 Cornil and Babes, bacilli as well as micrococci ; Wilson, cultivations ; Mantle, cultivations; Petrone, the organisms described by Klebs in rheumatic endocarditis ; J. P. Popoff and Birch-Hirschfeld, staphylococci or streptococci in joints and valves; Bouchard and Charrin, staphylococcus ; Triboulet, staphylococcus albus and aureus ; Sahlz, staphylococcus aureus ; Sacaze, staphylococcus albus ; M. L. de Saint Germain, experimental arthritis by intravenous injection of staphylococci; Professor Leyden; and more recent observations are quoted by Pribram, Der Acute Gelenkrheumatismus (Nothnagel, Specielle Pathologie und Therapie), Band v., Theil i., Wien, 1899.

762 direct evidence is still wanting, cogent arguments are based The well-known influence of injury, fatigue, and chill, all of upon inference by Newsholme in favour of a microbic which lessen the resistance of the individual, is analogous to nnaterieg morbi, saprophytic with a tendency to parasitism, the personal factor of inherited immunity or predisposition ubiquitous in distribution but restricted in its spread by the and cannot be regarded as negativing the infective theory. complexity of the conditions requisite for its growth, essen- Finally, there is the weakness of the alternative theory-the tially a soil organism and’perhaps, like tetanus, capable of lactic "acid theory of Prout, Todd, and Richardson, its chief becoming pathogenic only when directly inoculated ; and the clinical evidence being derived from Sir Walter Foster’s* question is asked whether rheumatism is a purely miasmatic observations. In his two diabetic patients the prolonged disease, like ague, in spite of the prevalence of the two administration of lactic acid preduced a rheumatic fever, but diseases being apparently connected with opposite conditions D. A. Harkin9 has suggested that this might have been gout of soil and of rainfall, or a miasmatic contagious disease like in disguise as the small joints were chiefly attacked. At any enteric fever. rate, if lactic acid were developed in excess this would occur The epidemiologioal arguq7tent.-Af ter suggesting that infec- through the agency of a micro-organism, which would be, tion might be conveyed (a) directly from person to person according to Newsholme, the essential cause of the disease. or (b) indirectly from infective discharges gaining access to THE PROPHYLAXIS OF RHEUMATISM. the soil from water, milk, or other foods, or from desiccaIn this direction suggestions are still wanting. The tion in habitations, Newsholme4refers to the prevalence of benefits of notification are largely due to a stimulation of the disease being occasionally concentrated in certain cities, clinical observation and thought; and in the case of or ia streets, or even in houses. Important instances of rheumatism the clinical method is specially recommended these local epidemics are quoted. Ch. Fiessinger5 reported by the fact that none of the general determining factors of that in a village of 500 houses 10 out of a total of 21 cases rheumatism possess the same prominence as the individual observed in recent years had occurred in one street, four factor of predisposition. fresh General prophylaxis.-Pending occurring in the same house, and two in the same room. bacteriological Edlefsen,6 at Kiel, found 728 cases occurring in 492 houses revelations general prophylaxis seems to be limited to the (100 houses for 108 cases)-viz., two cases occurred in one scope of sanitation. Yet our modern improvements have house 100 times, three cases in one house 27 times, four cases not, as in the case of phthisis, resulted in a steady decrease; in one house five times, five cases in one house five times, six but the recrudescences which have occurred from time to time cases in one house once, and seven cases in one house once. are consistent with Newsholme’s view tnat desiccation of the Friedlander in the discussion on Edlefsen’s paper stated that subsoil may be at the root of the evil, since during recent out of 357 cases eight cases occurred in one house twice, years droughts have coincided with an increasing consumpseven cases in one house once, five cases in one house once, tion of water by the water-supply companies. But it is not four cases in one house eight times, three cases in one clear how this general indication is to be met. On the house ten times, and two cases in one house eight times. other hand, we still trust to an obvious indication for Mantlehas recorded multiple cases in the same house, also desiccation of the surface soil, and particularly of the sites an instance of rheumatism running through a family. The for houses, as well as of the habitations themselves. The epidemic spread of rheumatism does not occur with explosive prophylactic indications connected with climate and mineral rapidity as does that of measles or influenza, but with slow baths can only find their application in connexion with the and creeping progress, like that of diphtheria, taking years individual. to invade a country and years to die out of it. Individ1lal propkylaxig.-In individual prophylaxis we The general conclusions reached from a study of the seem to have hitherto neglected or missed our opportunities. Scandinavian returns of cases and other returns are :-1. Where does the weakness reside which lays a child open to That considerable irregularities occur in the yearly incidence insidious rheumatism or an adult to rheumatic fever, when of rheumatic fever sometimes such as to deserve the term others undergo the same depression, fatigue, or exposure " ’’epidemic" 2. That there are two kinds of epidemics, the with impunity ?1 By what sign shall we tell the special preone "explosive," terminating in one year or at the most disposition ? And if able to suspect its presence, how three years, and the other "protracted," chiefly observed in shall we best arm the subject against it ?1 A study of large centres of population, or in connexion with the the features characteristic of a rheumatic predisposition statistics of an entire country, being possibly made up of the and of the earliest rheumatic premonitions or of the prefusion of two or more explosive epidemics. 3. That the rheumatic state is an obvious requisite. For instance, as favourite years for epidemics in England were 1855-56, 1859, regards the general physical appearances, although physicians 1864-65, 1868-71, 1874-76, 1884-85, 1888, and 1893. 4. That may have derived general impressions from a prevailing tenno absolute periodicity can be traced though epidemics are dency to pallor, sallowness, imperfectly cleared skin, and apt to recur at intervals of three, four, or six years. But in the like, they have not been able, so far as I know, to frame many instances a regular alternation may be traced between a typical I I facies " peculiar to the predisposition ; but to the explosive and the protracted epidemics-two of the this point I dare not devote further time. former occurring between each two of the latter. Rheumatic tonsillitis.-The great frequency of rheumatic The clinical argitnient.-Much stress is also laid upon tonsillitis has - its significance. The tonsils, which are certain clinical features which are analogous to those of strongly suspected of introducing and of harbouring the recognised specific fevers-viz. : (1) the mode of onset germs of phthisis, have also been suggested as portals of (shivering, general aching, &c.) ; (2) sore throat (80 -per infection by the supporters of the infective theory of rheucent. of cases, J. K. Fowler) ; (3) the progress of the fever matism. But there are other sufficient reasons for not and its various complications, particularly endocarditis (all neglecting them as possible factors in the disease. May not diseases leading to the latter being, except perhaps chorea, indications be traced in their behaviour or aspect which known to be infective) ; (4) the tendency to relapse might aid us in recognising the rheumatic proclivity?1 (relapses are common in erysipelas, pneumonia, influenza, Again, is the frequent immunity from arthritis, in spite of &c.) ; (5) the incidence of the disease mainly upon the a liability to carditis, in any way connected with the more joints, where the infection is buried (this might be an active function of the tonsil in early life ? Can anything be explanation for the absence of any perceptible contagious- achieved by treating the tonsils which could in any way ness) ; and (6) the specific power of the salicylic remedies influence the rheumatic bias ? This practical question might which is compared with that of quinine in malaria and of conceivably be answered by the results of surgical interthe iodides in syphilis. Personal proclivity, which may be ference. Has the rheumatic tendency been favoured or in regarded as inherited, largely determines individual liability, any way affected by a removal of the tonsils and of adenoids? as in all infections which are widespread or ubiquitous. If any connexion were traceable between the rheumatic As to the channel of infection Newsholme believes that it tendency and the behaviour of the tonsils valuable indicalies through the tonsils or some part of the naso- tions might be gained by a systematic examination of pharynx. Since all knowledge of the incubation period children at schools and in private practice with a view to is wanting we are able to think of a "latent parasi- prophylaxis. tism " as conceivable, the latent rheumatic infection Prophylaxis by climate, environment, and general managebeing suddenly called into activity in individuals ment.-This includes the most important indications, which apparently healthy and not exposed to any infection. are also those least within reach for the majority, particularly as regards selection of circumstances ; and much is 4 Loc. cit. Gazette Médicale de Paris, No. 14, April, 1892. Zur Statistik und Aetiologie des acuten Gelenkrheumatismus. 7 Brit. Med. Jour., June 25th, 1887. 5

6

8 9

of

Synthesis of Acute Rheumatism, Brit. Med. Jour., Dec. 21st. 1871. Pathology and Treatment of Acute Rheumatism, Dublin Journal Medical Science, vol. lxxii., 1881, p. 312.

763 also implied which it may become easier than it now is to formulate. Prophylaxis against a disease so largely affecting young life cannot in cases of suspected indisposition be undertaken too early, perhaps even in infancy, with the twofold object (1) of avoiding individual exposure, and (2) of increasing individual resistance to its causes. Early childhood and early school days are the special periods during which watchfulness is needed, for there is reason to believe that among the poor the predisposed children fall early victims to their adverse circumstances when, in addition to the evils of damp, of cold feet, and of underfeeding, there is a wasteful leakage of energy wanted for visceral innervation into the .service of mental effort and school worry. We learn the importance of schools being removed from town into country. For predi;posed children the selection of schools should be largely guided by considerations of school hygiene and of local climate, atmosphere, and soil, concerning which we yet know too little. Is rheumatic fever ever developed at sea ? Is the rheumatic tendency counteracted by marine climates, and if so, by which variety, the soft or the Too much stress cannot be laid upon the importance of management and regulation of the alimentary functions in this form of delicacy. Errors in quantity and in quality of the food, imperfect digestion, unrelieved bowels, checks, both acute and chronic, to the action of the liver, lymphatic embarrassments, which are passed over as trivial in average children, are dangers to the predisposed, and the physical appearances, particularly those of the complexion, abdomen, tongue, and pharynx, may be health-saving guides. Prophylaxis by d’r1tgs.-Is salicylate indicated7 Various remedies will serve the purposes of internal hygiene, but information is needed as to the tonics best suited to counteTact the early rheumatic bias. With special reference to the iodides and to cod-liver oil are the indications analogous to those approved in the scrofulous predisposition?2 But our most immediate concern is the prophylactic use of antirheumatic remedies at all stages of the liability. Belief in the specific virtues of the salicylates would almost imply as a duty its systematic administration in all threatened individuals. Unhappily, that belief is shaken by instances in which fresh arthritic attacks have occurred whilst the patients were taking salicylates. But putting aside that doubt some good probably results from periodical courses of salicylate treatment for the sake of its hepatic action. The responsible question remains, " Can its continuous" administration be detrimental, particularly to the young ?

bracing ?

rheumatic polyarthritis. In its most acute form, which we may suppose represents the true type of rheumatism, the polyarthritis is conspicuously non-symmetrical. It is erratic as well as migratory, attacking first, it is said, those joints which were most in use, but subject to no obvious rule in its wanderings. Symmetry, when it does occur-and this is perhaps not more frequent than belongs to the law of chances-would seem to be an exception rather than the rule and a departure from the purest type. 4. "Symmetrical rheumatism," acute and subacute. In some cases, usually not the most severe and often subacute, symmetry is a prominent feature of the arthritis. The more I have looked for this symmetrical condition the more frequently have I found it and the more have I been impressed with certain peculiarities in the cases which presented it. The following tabulation of the rheumatic series is an attempt to follow out the gradual transitions which may establish a distant connexion between its two extreme representatives. Chronic fibrous rheumatism, which is not included, would unnecessarily complicate the table.

THE VARIETIES OF ACUTE RHEUMATISM, WITH SPECIAL REFERENCE TO THEIR LIABILITY TO CARDIAC COMPLICATIONS. In spite of its rapidly advancing cleavage the rheumatic group is still unwieldy. Its recent contraction owing to the identification of various specific microbes or toxins may be argued in support of, though truly it may also be argued in opposition to, the assumption of an infective nature of the remainder. Pyasmio, gonorrhoea.1, post-zymotic, and other secondary arthropathies are no longer spoken of as rheumatism; and as to those infective forms which have been less completely differentiated, the name pseudorheumatismsufficiently declares their dissociation from the group. Whether a single or several specific infections may yet be detected in the latter will be determined by further bacteriological studies ; at this stage a purely clinical analysis of its members would seem to be possible and expedient. But any sorting of our cases is merely prcvisional. In phthisis different types of disease have been constructed when the difference was simply between the constitutions or structural peculiarities of the subjects, and the same might happen with rheumatism. The distribution of the arthritic lesions.-Arthritic lesions, as regards their local incidence and their varying tendency to localisation and the order of their migrations, are tangible features which may serve as indicators to the more essential but less obvious contrasts and affinities between acute rheumatic and rheumatoid arthritis. Four broad types stand out clearly. 1. Monarthritis. Whether rheumatic or rheumatoid, this is in both affections an outlying and mysterious variety, equally untrue to the accepted definition and to the usual type of either, and therefore straining all our theories. 2. Symmetrical rheumatoid arthritis. A systematic bilateral and symmetrical progress is typical of rheumatoid arthritis, both acute and chronic, and in strong contrast with the third type. 3. Non-symmetrical or erratic

CLINICAL CLASSIFICATION SHOWING TRANSITIONAL VARIETIES. -variety (a) : with symmetrical, permanent incurable deformity. I. Chronic rheuma(b): with symmetrical deformity arthritis. toid arthritis. toict -’ capable of some degree of

SU

.

-

.

l

recovery.

B_

II. Acute

y sub- )

and acute rheumatoid ) arthritis. r

.’

(c): distinctly "rheumatoid"; heart not affected.

(d)"rheumatoid " in the local persistence of its joint lesions and " rheumatic in its heart lesions.

’

"

III. Acute symmetrical rheumatic’ arthritis,

(e):

with

persistent and refractory joint mischief (a rheumatoid feature) with or without heart lesion.

,,(f): with transientjoint and no lesion. "

(g):

mischief heart

permanent

with permanent heart lesion and transient joint lesion.

with-

"

..

(h):joint pains only (usually bilateral) with cardiac lesion. (t) febris rheumatica sine arthri-

f‘I polyarthritis. polyarthritis. l

"

(j) :

IV. Acutee cardiac rheumatisma out arthritis ("juvenile" type).

tide.

V. Acute

» "

without heart polyarthritis lesion. with heart lesion. (7-):

polyarthritis (L) ;hyperpyrexia and various acute

complications.

In the fifth group polyarthritis," a sub-variety (j), is made up of cases without heart lesions. The percentage of the latter may eventually be found to be less common in the acutest rheumatic attacks and weighty questions of treatment might be opened up thereby ; in this connexion it may be helpful to remember that the most active production of valvulitis occurs in Group IV. from subacute and almost latent attacks in the young. Acute symmetrical rnmlmatisrn.-Among those other purely tentative distinctions suggested as possible helps to study special attention is called to Group III. and to its sub-varieties. The acuteness of the arthritis in this symmetrical rheumatism has seemed to me to be usually not of the first order, but its tendency either to stay or to return is exceedingly marked. This peculiarity may be developed to any degree from that represented in the sub-varieties (f) and (g) where the symmetrical affection of the joints closely resembles, but for its systematic distribution, the ordinary acute polyarthritis, down to the condition found in subvariety (d), where the persistent or steadily relapsing character of the arthritis and the eventual deformity identify the case as "rheumatoid,in spite of its originally purely ’’ rheumaticappearances and of the heart lesion which is so frequently found to co-exist. Indeed, the most important of the features of the whole group is the frequent implication of the heart. It would be important to determine whether the cardiac lesions are, as I think, always of the verrucose type rather than of the vegetative, and whether pericarditis is or is not relatively more frequently associated with it than with the non-symmetrical

varietv. The practical difficulty of separating the rheumatoid subvariety (d) from the rheumatic sub-variety (e) is great, so closely do some of the cases in the latter imitate the rheuIn some of these acute or subacute matoid characters. rheumatic attacks the affection is confined to, or settles

764 a pair of joints where it remains in possesin spite of salicylates ; or it may relapse again and again for weeks. This form is highly suggestive of the rheumatoid arthritis type except in two particulars: the joints get quite well, but the valves are commonly affected. The juvenile type, where the joint swelling, stiffness, or pain are bilateral, is analogous to this merely in respect of the great prevalence of the valvulitis and of the relative mildness of the arthritis. The local persistence of the arthritic process (often limited to one pair of joints) and the frequent absence of response to salicylates suggest that some cases hitherto considered rheumatic are really the most acute form of rheumatoid arthritis and of a rheumatoid arthritis I which tends to affect the heart. This also suggests thatI forms yet some of the acute, more strictly rheumatic, may partake of the rheumatoid characters. This large group may be a link between the ùwo affections or it may be merely a sphere common to both where the individual presentments of the two types are apt to be so alike that we cannot distinguish between them. With less ofthe profuse sweating there has been more of the "rheumatic"cutaneous rashes. It is, indeed, significant that not only the rheumatic exanthems but the eruptions of subcutaneous nodules are almost invariably bilateral events and would fall within the lines of this group. From the point of view of treatment the common failure of the salicylates to relieve the arthritis might lend support to Dr. A. E. Garrod’s view that their chief efficacy is in the control of the hypersemic and more ephemeral forms of arthritis rather than of those associated with fibroid nodules and with warty valvulitis.

quite early in,

sion

i

..ll::1.tJ;

IJALtti.LL:1’1’r:,J

-a.

’1’tlltL

lU.UJJJj;


t11i11VB.

Historical and comparative details relating to these remedies are less fitted for my brief opportunity than the main questions as to their mode of action and therapeutic value. Is this treatment to be regarded as a specific treatment ?7 Why does it sometimes fail to relieve the arthritis and the fever ?7 Why does it usually fail to cure and to prevent the cardiac complications ?7 Idiosyncrasies are met with in the use of remedies as in the use of foos ; neither can we be sure that the same chemical reactions occur in all individuals after the administration of identical substances. Moreover, it is conceivable that the patients reacting in different ways may not be suffering from identical forms of the disease. Similarly it might be argued that the failure to check heart affections may be due to purely cardiac reasons in spite of a truly anti-rheumatic action. These reservations need to be stated, although opinions may differ as to their value. The mode

of action of salloylates.-If the mode of action of salicylates could be better understood it would probably throw light upon the disease. At least three views may be entertained.

The action may be that of

a

sedative, that of

antiseptic or microbe destroyer, or that of a metabolic or antitoxic remedy. 1. According to the first view salicylic acid might be regarded as acting even more as a nerve check than in any other way, suppressing the pyrexia through its influence upon the nerve centre and allaying the local inflammation by its influence upon the peripheral vaso-motor mechanisms. In this it perhaps operates in the same way as some modern antipyretic and analgesic remedies, the rapid

an

salicylic radical would be required to combine with it in the shape of salicyluric acid and thus to prevent a further production of uric acid which in Latham’s view tends to paralyse some departments of the vaso-motor centre. It has been objected to this chemical theory that we do not possess sufficient evidence of the presence in the blood of any excess either of lactic acid or of uric acid. But it affords some explanation for the excessive acidity present in acute rheumatism and for the presence of salicyluric acid as a decomposition product in the mine. The excretion of salicylates.-In addition to the sa.licyluric acid a large quantity of salicylic acid is generally held to be excreted unchanged and musb be carried by the blood; hence the danger of its administration in renal impermeability. The occasional disastrous effects have been attributed to a definite impurity in the manufactured acid, but in renal failure they may be due to its mere retention or to that of its products. that the drug might not be entirely eliminated as salicylic and salicyluric acid and that some of it might be split up into its synthetic components-carbonic acid and carbolic acidand that the latter might be excreted as ethereal sulphate, I availed myself of Mr. J. Addyman Gardner’s kind offer to analyse the urine from two patients during periods of freedom from salicylate and periods of its administration. The results were conflicting, indicating in one instance a rise and in the second a fall in the ratio of the ethereal sulphates to the metallic sulphates, and can only support the inference that if any phenol is produced in small quantities by a decomposition of the salicylate the amount excreted as Further investigation may sulphate is inconsiderable. lead to definite conclusions. If phenol and carbonic acid were liberated even from a small proportion of the large doses taken toxic results might arise. Perhaps some of the toxic results are due to them. The lividity peculiar to subjects overdosed with salicylate and other symptoms pointing to an increased venosity of the blood might be due partly to the carbonic and partly to the carbolic acid, and the major toxsemic events to an accidental increase in their amount in circulation. On the other hand, it is conceivable that the beneficial effects of the salicylate might be usually due to these agents, both of which are general as well as local anaesthetics, their minimal production explaining why such large quantities of the drug, most of which passes out apparently unutilisecl, should have to be put into circulation before a specific benefit can be obtained. It is interesting to find that subcutaneous injections of a 1 per cent. solution of carbolic acid had been used by Marder (1873) in three cases, by Kunze (1874) in four cases, and by Senator (1875) in 25 cases (in one of which a 2 to 3 per cent. solution was employed) with excellent results as regards the pain and other local symptoms which were relieved or entirely removed ; but this treatment did not ward off complications or relapses. Little or no impression was made upon the pyrexia. The pain was controlled sometimes within an hour. It was only within the last 12 months whilst seeking for a simple remedy which might reduce the coagulability of the blood and whilst still unacquainted with the results just mentioned that I gave a trial in a few cases to the other less dangerous decomposition product, and that I found that the effects of inhalations of carbonic acid gas agreed to some extent with those just stated in connexion with carbolic acid. The pain was lessened or relieved, but the improvement in the joint which in one case was marked was not in others sufficiently obvious to induce me to defer other methods of treatment. It was specially noted that the temperature did not improve in the same ’proportion as the local symptoms. The upshot of these two independent lines of inquiry may perhaps justify further research in the same direction.

Suspecting

action of which is, it would seem, mainly sedative and apparently due to the liberation in the blood of some of the constituents of their unusually comActive whilst their supply lasts they plex molecule. are comparatively powerless to modify the course of the disease for which they are administered. 2. So long as the existence of a specific micro-organism lacks full demonstration the second view must remain a postulate and cannot be discussed with profit. 3. Greater importance THE PLACE OF SALICYLATES IN OUR TREATMENT. attaches to the theory that the remedy corrects some fault in the blood or juices either by neutralising an infective This form of treatment is now a routine, hardly questioned toxin or by deaiing with the products of an unhealthy from a critical standpoint by the prescriber. On this occasion metabolism. This central rectification might be brought unreserved criticism may perhaps be opportune. First, can about merely by an increased activity of the normal pro- the drug do any harm ? It is known to do harm in all cases of tective function of the liver, for the drug is a powerful renal impermeability ; the question is how far it may disagree hepatic stimulant ; and there need then be no definite pro- in varying individual degrees of renal inadequacy or portion between the quantity of the morbid material and idiosyncrasy. Even in the normal subject the indirect risk that of the drug opposed to it. According to Professor arises that we may be misled into over-estimating its antiLatham’s theory this proportion would be constant; the rheumatic powers and relax too early both treatment and diet. greater the production of glycocine, for this is held to be Upon this I need not dwell. On the other hand, may the with lactic acid the faulty product arising from an assumed drug be withheld without any detriment ?7 If it were shown vaso-paralysis in the muscular area, so much more of the to be powerless to prevent endocarditis, myocarditis, and

765

pericarditis, or to control the warty valvulitis by which patients whom he formerly treated exclusively with sodium are ultimately destroyed, this fact would liberate us bicarbonate than under the modern salicylate treatment. The immediate suppres- Dr. W. Howship Dickinson16 in a paper entitled Alkalies in as regards the choice of treatment. sion of the obvious and painful symptoms being of secondary Rheumatism gives the result of long observations including valves

to an immunity from endocarditis, it 28 cases not treated with alkalies in which more than oneneed not be our rigid duty to administer it forthwith, but third presented heart affections. Nitre gave better results— it would be our stringent duty to use any other drug capable viz , one in five—but the full alkaline treatment (such as to of controlling heart complications. Experience has shown keep the urine constantly alkaline) had given in Dr. H. W. that no appreciable harm befalls a joint from the worst Fuller’s hands one instance only in 48 cases. Making all attack of acute rheumatism, even should the relief of the reservations for possible errors in observation Dr. Dickinson arthritis have been delayed for a few days. The evidence ascribes the remarkable difference recorded to the influence which this debate will elicit may perhaps enable us to answer of the alkalies in preventing the coagulation of fibrin. He this second question in the affirmative. Much will have been has invariably employed the alkaline treatment during later gained if any misconception can be removed by which the years in conjunction with the salicylate (a drachm of potasprogress of therapeutic research and of the prophylaxis of sium bicarbonate with 15 grains of sodium salicylate at intervals of two or three hours until the urine becomes valvulitis might be longer delayed. The relative frequency of heart lesion 1tnde’l’ salicylate alkaline and then every four hours day and night for many treatment.-This question lies at the root of our future days), with the result that there was less endocarditis, less therapeutic action. In recent literature’" we meet again pericarditis, and fewer relapses than under any other treatand again with the ominous statement that since the general ment, whilst slight apex murmurs or abnormal sounds have adoption of the salicylate treatment cardiac complications been noted to disappear. have shown increasing frequency. If this result were due The statistical results collected at St. George’s Hospital17 to the drug the remedy would be worse than the disease; by Dr. R. Sisley, Dr. Lee Dickinson, and Dr. Cyril Ogle during it might, however, have occurred in spite of the drug. their successive registrarships show that "224 cases of acute Those who believe that the latter may be capable of rheumatism were admitted with the heart not affected at damaging the heart (Jaccoud ll) are consistent in abstaining the time of administration ; 162 had full alkalies together from its administration. The plea put forward for its almost with the salicylate. Of these three developed endocardial general use in spite of our ignorance a,s to its mode of murmurs while under this treatment. Several developed action-viz., that some protection is afforded to the heart murmurs and pericarditis after the alkalies had been relaxed by the lessened duration of the rheumatic attack- or discontinued. 62 patients were treated with the salicybegs the question in assuming that the cause is late alone, under which five developed endocarditis and one relieved as well as are the symptoms of rheumatism. pericarditis also. The conclusion is that under full alkalies Pribram,12 whilst referring to the surprising differences and while under them one case in 54 displayed heart affecbetween the estimates derived from various sources and tion; under the salicylate by itself one case in 12." Referwhilst stating that endocarditis is more frequently observed ence is made in Dr. Ogle’s report to cases where the now than formerly, endeavours to minimise the significance heart though not natural on admission became so under of these facts by pointing out that a similar increase has treatment. In connexion with the conclusions which attribute to the occurred in connexion with other infective affections, and may be due to increasing care and facilities in clinical alkaline treatment an almost specific power over rheumatic diagnosis. This is another of those questions which cannot affections of the heart attention should be drawn to the be solved without large as well as reliable statistics. Mean- question as to the special form which it should assume. while important contributions have’been made in that direc- First, should potassium be the alkaline metal employed ? tion in Dr. T. T. Whipham’s valuable Report to the Collective Its alkalising power is much greater but it is more depressInvestigation Committee and by Dr. Howship Dickinson’s ing. Sodium salts administered by some observers are less study of the records of rheumatism at St. George’s Hospital, depressing, but considerable quantities are usually required extending over a long period. To these data reference will to bring about the alkaline reaction of the urine. In the be made under the heading of The Alkaline Treatment. second place, should preference be given to the hydrate, to the carbonate or bicarbonate, or to some other organic salts THE ALKALINE TREATMENT. of these metals ? The choice between the latter and the A modern argument in support of a practice which is carbonates is apparently somewhat simplified by the circumregarded by some as old-fashioned is supplied by Fodor’s 13 stance that all organic alkaline salts are reduced in the experiments which show that some protection is afforded economy to the state of carbonates. But whilst under the against various infective inoculations by the preliminary same weight a much larger proportion of the metal is administration of alkalies; but the evidence by which administered with the bicarbonate than with the citrate Fuller’s alkaline treatment 14 must stand or fall is neither of for instance, the decomposition of the former is not delayed. this kind nor chemical or bound up with the correctness of Its introduction into the stomach is immediately followed the lactic ;acid theory, but clinical, and to its consideration by an evolution of carbonic acid gas which becomes availwe must at once proceed. able for absorption and possibly for the therapeutic influence Clinical testimony as to the good results of the simple which has already been pointed out. There is, however, alkaline treatment is further supported by general inference another not unimportant aspect to the frequent repetition of derived from the natural history of the affection. The ’, the large doses in which this salt is administered. I have excessive acidity of the urine, the readiness with which the had reasons to suspect that the almost permanent inflation to

importance compared

alkaline perspiration undergoes an acid decomposition, and, which the stomach is thereby subjected whilst in an above all, the fact that hyper-fibrinosis is a condition gene- adynamic and underfed condition may be answerable for rally associated with a diminished alkalescence of the blood, some of the cases of temporary or even permanent dilatation are weighty arguments. Again, the behaviour of tissues of the stomach to be observed after a protracted attack of under the acid sting of various animals and plants and in ’, rheumatic fever treated with the bicarbonates. This urticaria and the relief given by alkalies are at least point should be borne in mind in the eventual determination of the most suitable alkaline salt. suggestive. The alltaline treatment ira connexion 1vith the prophylaxis of endocarditis.-Pribram,15 after analysing the returns ARE SALICYLATES TO BE PRESCRIBED ALONE OR WITH AN ALKALI? published by Fuller, Furnival, Chambers, Senator, Thompson, ’, and others in connexion with the relative frequency of ’, an adequately extensive inquiry sufficient has Pending cardiac complication, refers to his own experience to the ’, been said to indicate the importance of the practical question effect that heart complications were less frequent among the as to how to administer the salicylates to the best advantage. I In view of the interests at stake it cannot be matter of in10 Cf. difference whether we give or withhold the alkali. It is Pribram, loc. cit., p. 464. 11 Cf. Pribram, loc. cit., p. 464. enough that the two plans should yield diverging results in 12 Loc. cit. 13 Cf. Pribram, p. 426. one of them must be the better 14 Acetate of potash, two scruples ; sodium bicarbonate, one drachm ; connexion with the heart; citric acid, two scruples ; water to three ounces every four hours until the urine becomes alkaline, subsequently twice daily, in conjunction 16 Cf. Occasional with a low diet and in cases where the urine becomes persistently Papers on Medical Subjects, 1356-96, London, 1896 alkaline with quinine or bark, which Barclay (1877) found to clear the also Transactions of the Royal Medical and Chirurgical Society, vol. xlv. urine of phosphates when supplied in sufficient doses. 17 Loc. cit. 15 Loc. cit., p. 423.

766 and should be

preferred. A strong case has been made scarlet fever, and since most children also escape cardiac salicylate method ; for the other rheumatism, the endothelia of those who suffer may be method no positive argument has been advanced so far as I regarded as specially vulnerable. This brings to mind the know. There would seem to be a natural fitness in asso- analogous liability, tiaceable through families, to the changes ciating in our treatment two remedies the virtues of which of atheroma. We are also reminded of individual differences noticeable in the skin, particularly in relation to eczema. seem to complete each other, the sphere of the salicylates of the Some skins develop eczema under the slightest provocationy the and of the control arthritis, pyrexia rapid being that of the alkalies the control of the tendency to endo- others even under strong irritation are almost incapable of carditis. But it is essential that we should learn from it. An analogous vulnerability of the endothelia, such as is overwhelming evidence the full extent of the advantage seen also in phthisis, might explain some of the rheumatic which our patients might gain. Meanwhile, a hope has been events. The peri-articular rheumatic swellings and the inraised by Dr. R. Caton’s 1’ favourable report on his treatment flammatory exudations occurring in situations where no by a series of small blisters together with the administration blood-vessels are found and at the surface of serous memof sodium or potassium iodide that the best results of the branes might possibly be viewed as the result of damage to a combined alkaline and salicylate treatment may yet be specially vulnerable lymphatic endothelium. To this might be partly due the oedema of the extra-vascular tissues of the surpassed. plan

out in favour of the alkaline

THE THERAPEUTIC ACTION OF SALICYLATES IN ITS BEARING UPON THE PATHOLOGY OF RHEL’3IATIS1I AND OF THE RHEUMATIC HEART AFFECTIONS. It is noteworthy that salicylates do not depress a normal temperature-a circumstance pointing rather to a sedative action than to one upon the metabolism of the body. Dr. Archibald Garrod distinguishes between the hyperaemic and the fibrous rheumatic changes and ascribes to salicylate treatment considerable power over the former. Possibly the refractory cases are those which present pre-eminently the latter tendency. The tendency of some of the 11 symmetrical"as well as of all monarthritic attacks to become localised agrees with that view. The same distinction between the hyperasmic, fluxional, or vaso-motor and the fibrous morbid changes has an important bearing upon the pathology of the cardiac lesions. But when we turn to the valves which are the chief seat of the cardiac lesions the nervine theory has no place. Our pathology becomes, like the tissues of the part, independent of vessels and of vasomotor nerves. Cells and juices are the only material for our speculations. The juices, known to be unhealthy with that tendency to hyperfibrinosis which is common to all pyrexia but is specially conspicuous in the acute rheumatic state, probably irritate and swell the intercellular channels and the cells which they permeate. The endothelial cells probably suffer most from the rheumatic malnutrition, perhaps even to the pointt of Local deposition of fibrin is necrosis and disappearance. the disastrous mode of repair which finally leads to fibrosis and crippling of the valve. Whilst the vascular membrane suffers in this way similar influences probably overtake the endothelia of the lymph-channels. These changes need further study; they may include swelling of endothelial cells, inspissations of lymph, and partial obstructions. We can judge only of their results in the shape of infiltration and swelling of the fibrous tissues. These two agencies respectively at work at the surface of the valves and in their thickness combine to bring about the well-known changes of valvulitis. From this simplified conception of the valvular lesion we may work back to the arthritic morbid processes and distinguish in them a mainly extravascular set of changes which in some varieties of arthritis are inveterate and refractory to our present methods of treatment, and the vaso-motor changes represented by the passing hyperaemic and fluxional swelfings which so rapidly disappear in favourable cases under the influence of salicylates. If these views be correct we may regard rheumatism as largely made up of a perverted metabolism and of its damaging effects upon the lymphatic structures, including in some cases the serous membranes, and, on the other hand, upon the vascular endothelium. The failure of salicylates to check the cardiac complication need not imply that the rheumatic process in the heart is different from that in the joints. The mechanical conditions alone differ. The joints There is, can rest, but the heart and its valves never do. however, another paramount determining factor, that of

predisposition.

Ercdot7aedial vulnerability.-The frequency of zymotic or valvulitis and arthritis may bear the interpretation that in early life endothelial structures are singularly susceptible, particularly in those extravascular tissues which are exposed to much work, such as the membranes of the valves and the joint structures. Yet, since not in all children, but in a minority only, is the heart affected after measles or

post-zymotic

18 R. Caton, THE LANCET, August 17tb, 1896, p. 399. Cf. Edinburgh Medical Journal, 1899 ; also Transactions of the Clinical Society of London, March 9th, 1900.

valves, the surface lesions of which

are lesions of the vascular endothelium. If this excessive vulnerability could be identified in its bearers at an early age the road might be paved to an efficient prophylaxis.

THE RHEUMATIC HEART COMPLICATIONS AND THEIR PROPHYLAXIS. Whilst the recognition of fully-developed rheumatic fever presents no difficulty the same cannot be said of the minor and insidious forms of acute rheumatism. Leaving aside the list of pseudo-rheumatisms which includes various articular affections referable to toxic and to infectious agencies, variability in the localisation and in the degree of the lesions is a prominent feature of the rheumatic group. Any implication of the joints is readily ascertained, but the condition of the heart cannot in a large proportion of cases be determined with certainty. Though no murmur be audible it is impossible to prove the complete absence of some minor affection, the signs of which may develop only at a late stage. The researches of Dr. D. B. Lees and Dr. F. J. Poynton have raised our estimate of the frequency of rheumatic carditis and its results as distinct from simple valvular affection. Indeed, it is a safe rule to frame our treatment on the assumption that the heart is threatened in all rheumatic attacks. Its continued activity, not always restrained by a merciful immobilisation of acutely inflamed joints, is an abiding risk. Nevertheless, we have reason to believe that it is not in every case inflamed or strained beyond its normal holding. Judging from rough clinical standards and from the progress of cases the occurrence of pericarditis is the exception and that of myocarditis and dilatation is far from being the rule. Not only is valvulitis the prevailing danger, but, as pointed out by Dr. A. E. Sansom, valvular disease may often arise secondarily as a late result of changes which were

originally myocardial. Much importance attaches

to the fact that from the severe of febris rheumatica sine arthritide, again recently brought to notice by Dr. C. 0. Hawthorne, cardiac lesions may accompany every form of arthritis, but their frequency and their degree are not proportionate to the degree of the joint affection or to the intensity of the rheumatic attack. As hinted above, acute immobilising arthritis is in some measure protective to the Is it protective otherwise than in the measure of heart. the mechanical rest afforded? Is the heart less safe when the articular effusion as well as the pain has been dispelled ? This is a question with important therapeutical bearings. 77«? treatnient by vesication.-The claims of the treatment by blistering, which was introduced long ago by Herbert Davies and recommended by Harkin, will be dwelt upon with special authority by Dr. R. Caton and a few brief remarks will serve the present purpose. The evidence which has been produced is too important to be lightly put aside. Knowing that blistering is harmless we may avail ourselves of any help it may give. Multiple blisters over the joints (Davies) or a large blister over the heart (Harkin) would have equal opportunities of influencing and curing the rheumatism if, If this or as it was alleged by them, blistering is a cure. any other treatment were found to safeguard the heart we should not hesitate to give up the exclusive use of salicylates; but for the mere relief of the arthritis blistering the joints, although efficacious, is now in most cases just as superfluous as the ice-bags which were applied tothem long ago by Esmarch. Since the cardiac inflammations have not been prevented or suppressed by our internal medication they should not be denied any advantage such as that which praecord’ial blistering professes to confer. There are sufficient indications for a renewed inquiry in this direction both from a

arthritic attacks to the

cases

767

general therapeutical and from a sero-therapeutical aspect. I have been struck by the circumstances that immunity from heart lesions often coincides with very free arthritic effusion and general acuteness of symptoms. Is this a guide for our treatment of those cases where, as in childhood, little or no articular effusion occurs ? If so, prophylaxis might demand in predisposed subjects the application of blisters for the threatenings of an attack. The size and the frequency of application are practical points for discussion ; and for the supporters of the infective theory of rheumatism there is the additional question whether there might be any advantage in the re-absorption, from constantly recurring vesications, of systematic doses of a serum presumably endowed with anti-toxic properties, or whether the blisters should be treated by incision and allowed to act merely as revulsive, derivative, and counter irritant remedies.

THE GENERAL TREATMENTOF THE ACUTE ATTACK. It were almost presumption to touch upon this subject in this assembly were we not all conscious that in spite of the predominant position taken by the salicylate treatment considerable divergence still obtains in our practice and a brief The keynote of statement of views may be expected of me. the condition is general embarrassment of metabolism specially evidenced by the characteristic persistence of anorexia and failure of excretion. Chief and paramount is, therefore, the indication for free outlets, whilst supplies must be carefully measured. Purgation would seem to be the first and essential duty and it will be best carried out by remedies promoting the flow of bile. It has been a question in my mind whether rheumatic arthritis could long co-exist with diarrhoea. Extreme purgation could never be a suggestion of treatment, but no trivial consideration should interfere with a systematic and full relief of the bowel, Remedies which promote the tendency to perspiration-and this is one of the recommendations of salicylates-are indicated in preference to those likely to check it. The need for diuresis is sufficiently manifest in the loaded condition of the urine and is usually met by the diuretic properties of our remedies and by an abundant supply of fluids. These general measures efficiently carried out are a considerable portion of the cure, but the employment of special remedies should not be delayed. Probably the sodium salt of salicylic acid is the best to administer-though the strontium salt is favourably reported upon from America-and should be given in full doses. In the presence of albuminuria all salicylates should be strictly barred and we should rely upon a mild alkaline treatment. Alkalines have appeared to me to be the most essential part in the treatment in all cases, and whether sodium salicylate be also administered or not I venture to think that they should never be omitted. The potassium salts are usually preferable to those of sodium, and for reasons which I have explained the potassium citrate may be largely or entirely substituted for the bicarbonate. Both the alkaline and the salicylate treatment should be continued with diminishing frequency of administration for two weeks after the cessation of joint symptoms, and the urine kept alkaline during convalescence partly through the agency of diet. As the salicylate is diminished quinine, which may be needed from the first, is added or increased. Absolute rest in bed for a fortnight or longer and a gradual return to activity are rigid rules. Blisters may be applied from the first as a prophylactic measure, and as a curative measure in all cardiac affections, and especially in pericarditis. It is time that I should briefly refer to the iodides of sodium and potassium long in favour for the treatment of chronic rheumatism, also of undoubted service in the acute stage of rheumatoid arthritis and likely to be useful in some of the cases included in Group III. in the sub-variety (e) of the svmmetrical form of rheumatic arthritis when the skin is sufficiently tolerant. But it is in the treatment of acute rheumatism that Dr. R. Caton has brought forward strong evidence in favour of a specific action of the iodides, when combined with continued vesication over the chest, in preventing and in curing endocarditis. They would seem to be specially recommended by the influence which they exe cise upon the lymphatic system on the one hand and upon the blood on the other. I need not dwell upon the evidence of their power to facilitate the lymphatic flow which should be of service in removing the products of arthritis. A more important action may be exercised upon the blood. Iodide of potassium has been largely prescribed with a view to the consolidation of aneurysms. I have prescribed it in considerable for considerable periods, but after

doses

continuous treatment extending over months the post-mortem examination has revealed no clotting within the sac. This has led me to the conclusion that the tendency of the iodide is to lower the coagulability in spite of the favouring influence of a diseased arterial surface and to expect good results in a disease where the absence of clotting is the great end to be

secured. The potassium salt would seem to be best suited to the acute form of the disease, but in the rheumatoid cases and in the rheumatic cases approaching to the type of rheumatoid arthritis the sodium salt probably would prove less depressant and, so far as my observations go, is sufficiently satisfactory in the result. During convalescence iron is not tolerated unless associated with adequate purgation and alcohol is not needed in average cases. Attention must be paid to the varied requirements of individual cases. The heart being concerned gastric inflation should be guarded against and relieved. A totally different treatment, so far as I have observed, is called for in the monarthritic acute rheumatic attacks. THE LOCAL TREATMENT FOR ARTHRITIS AND THE CONSTITUTIONAL TREATMENT FOR RHEUMATISM : THEIR SEPARATE SPHERES AND THEIR COMBINATIONS.

Most of the acute rheumatisms are now treated exclusively by drugs. Sometimes drugs entirely fail and recovery is delayed until it is realised that the arthritis and not the rheumatism is the thing to treat. But other cases need a judicious combination. The proportion in which local treatment is needed may be roughly measured in individual cases upon that of the tendency to localisation, as I shall now endeavour to explain. The treatment of acute monarthritis.-Here little of the internal treatment which has been described is appropriate except that relating to the primæ viæ. The primary indication is to treat the joint (by splint and bandage, elevation, leeches or preferably blisters, inunctions, and graduated pressure) ; and the next to support the patient in the direction where support is most needed. Most often quinine or bark with nerve tonics and stomachics are indicated in addition to mild salines. A depressing treatment by salicylates and strong alkalies is worse than useless and its prolonged and unsuccessful trial often impairs the powers of recovery. The treatment of the " acute rheumatoid" and of the " symmetrical rheumatic " attacks.-As regards the necessity for local treatment the nearest approach to the monarthritic type is to be found in Group II., but the kind of local treatment needed may be totally different. As I have insisted elsewhere,19 in harmony with Fuller’s teaching many, though not all, of these inveterate or relapsing pyrexial cases, alike refractory to salicylate and to alkalies, are made worse by continued rest and are curable by movement and by a supporting treatment. But the acute arthritic swelling needs first to be subdued by Esmarch’s ice application or by ice-massage. None of the anti-rheumatic medicines or of the dietary restrictions are needed in these cases, the treatment of which cannot be given here in its full detail. This part of the subject would not be complete without a mention of the surgical treatment which has been advocated and practised by Dr. J. O’Conor of Buenos Ayres, but of which I have not had personal experience. Some cases in the same group have stronger rheumatic features and in that proportion may get relief from salicylates, though local treatment should not be neglected. But it is in Group III. that we find the chief variety of cases needing adjustment between the local and the constitutional treatment. Without attempting to enter into detail, instead of dealing with an unyielding attack by increasing and oppressive doses of salicylates we should trust to milder measures, those of internal hygiene and of diet, and to a saline treatment sufficiently alkalising to protect the heart, associated with quinine, nerve tonics, or stomachics, as each case will seem to suggest. The question of blistering the joints or the prsecordium is one which should be earnestly considered in this set of cases. The local measures may have to be tentative, like our medication, and may include leeching, ice massage, bandages, or even

splints. DIET. is the last part of my subject but by no means, in my estimation, the least important. The conclusions which

Diet

19

Cf. Medical Press and Circular, 1899. L

3

768

in ] !

wound. He was instructed to use a full-sized and to report himself from time to time, but as he remained well he did neither. Fancying, however, after a recent attack of influenza, that there was something wrong with his urine he came to see me. There was nothing amiss with the urine beyond an excess of urates, and I was able to pass a series of bougies of No. 10 (English) to No. 15 (French 26) easily and without pain. I usually select Maisonneuve’s instrument in these cases for the preliminary internal urethrotomy, as it will enter any stricture, however narrow, without any preceeding dilatation, by means of its filiform guide. Some prefer a urethrotome which divides the stricture from behind forwards, but I do not think this makes the least matter so long as the end of the instrument is fairly within the bladder. The kind of drainage tube referred to is made in different lengths and sizes in gum-elastic to fit the wound and deep urethra and bladder with as much accuracy as a tracheotomy tube fits a windpipe. From the day when it is inserted it commences to mould the repairing urethra to the dimensions required. It is readily used or temporarily removed for the purposes of irrigation and cleanliness, and when any slight risk of bleeding or oozing which might require side-packing is over its place is taken by a soft rubber tube with depressed openings of similar dimensions, Thus cicatrisation proceeds up to the time of its final removal. I first had these tubes made for me in the days when lateral and median lithotomy were On several occasions when there was common operations. oozing or free bleeding which could not be readily stopped I inserted one of the largest of these tubes, of about the dimensions of an average thumb, and closed in the incision around it firmly with sutures. This invariably arrested the bleeding, whilst the flow of urine remained uninterrupted and the patient was readily kept quite dry. This is the most effectual and convenient way of arresting I have reached the end of this cursory sketch of an almost bleeding in this class of operations. unlimited subject. The points for elucidation are many but I might have added further illustrations in correspondence they may be grouped under few heads and these have been with the case I have related where patients have been under sufficiently indicated. The main questions which I submit observation for long periods, but after what I have already for your discussion are : How shall we prevent rheumatism ? written elsewhere this is hardly necessary. External urethrotomy seems specially applicable to the and, How shall we put a stop to the rheumatic heart evil ? following classes of cases. 1. To resilient and rapidly contractile strictures in the deep urethra, which, like burn-scars, are unamenable to SOME REMARKS ON EXTERNAL stretching or dilatation and where a splice or an interval of new tissue is required within the circumference of the URETHROTOMY. contraction. It was in this class of cases where dilatation BY REGINALD HARRISON, F.R.C.S.ENG., had failed or recurrence had occurred that Syme first demonSURGEON TO ST. PETER’S HOSPITAL. strated the permanent advantages of this operation. 2. In cases where the wound made by an internal urethrotome is out of proportion to the natural drainage THE examination in the out-patient room of a patient who of the urethra. A wound may be so conpossibilities was operated upon for stricture by external urethrotomy over structed within this canal as to never drain completely a year ago gives me an opportunity of referring to some either in regard to urine or to its own discharges. psints connected with this operation to which I attach The result is much the same in these circumstances as what importance. The case may be taken as a typical one follows accidental lacerations of the urethra. Some years of its kind, of the details of the operation employed, and of ago I demonstrated in a considerable number of cases that partial ruptures of the urethra from violence, when treated the results to be aimed at. by perineal section and drainage, were no more promptly This patient was a man, aged 47 years, who had suffered liable to be followed by traumatic strictures than either a from stricture of the deep urethra for several years. He had median or lateral cystotomy for stone. I was led to draw been treated by various methods of dilatation but with no this conclusion and to apply it in practice by noticing that permanent benefit and attacks of retention, hsemorrhage, it was the slighter cases of ruptured urethra either not and cystitis had been frequent complications. At the end I treated at all or by the retention of a catheter which were of 1898 I took him into hospital and performed an external followed by the most dense and contractile forms of trauurethrotomy in the following manner. As the stricture matic stricture, whereas the severer cases, where the rupture would only receive a filiform guide an internal urethrotomy was so extensive or so complete as to render the introduction was first performed with Maisonneuve’s instrument. of the latter instrument impossible and to necessitate a Then a full-sized grooved staff was passed into the bladder section with bladder drainage, did the best and perineal to complete a perineal section. Exploration with the finger were much less liable tp the subsequent formation of a from the perineal wound enabled me to detect some stricture stricture at the site of the wound. Surgical cleanliness and 6bres which had escaped the internal urethrotomy and these were evidently important items in the prevention of drainage were divided with a probe-pointed bistoury. Then I could the latter. In dealing with any lesion of the urethra, made pass my finger readily into the bladder and forwards along either accidentally or surgically, we must feel fairly sure the urethra towards the external meatus, thus showing that that the unaided efforts of the wounded canal are sufficient the constriction had been completely removed. A full-sized to furnish adequate drainage, otherwise this should be gam elastic bladder drainage-tube was passed into the artificially supplied. It is reasonable to infer from these ladder and secured. For the latter a flexible rubber one observations that in the larger proportion of cases where was substituted on the fifth day and after 16 days’ drainage internal urethrotomy gives excellent results the operation and irrigation so as to keep the divided stricture thoroughly precisely fulfils the required conditions—namply. the comclearned the wound was allowed to close and the patient left plete division of the stricture by a wound which the urethra the hospital after a stay of three weeks. During the after- itself is capable of draining. It is no doubt possible in treatment the distal portion of the llretbra was washed out and kept clean by syrining from the external meatus and 1 Surgical Disorders of the Urinary Organs, fourth edition, 1893.

I may venture to put forward are that rheumatism is a dietetic disease and that in the wide range of our cases the " feeding" plan needs to be represented as well as the "starving"plan. In rheumatic fever the diet cannot be too light. Nature refuses food and the state of the tongue forbids it, but plenty of water is needed to clear the way for food. The source of the over-supply of lactic acid has been traced in our theories to the decomposition products of muscle and therefore meat and beef-teas have been generally held detrimental, but the inability of some patients to manage milk diet has led me to question whether milk might not in them keep up the rheumatic tendency and become the recurring supply of acid. There is evidence that fermentation is set up in the stomach as well as on the tongue and this is another source of dilatation of the stomach to which I would call special attention. I have arrived at the conclusion that administering a small quantity of salt (15 grains to the half-pint) or adding it to the milk is an important indication in all cases of exclusive milk diet and usually renders its previously difficult digestion easy. This is also an indication in dyspeptic infants who are sometimes supposed to be intolerant of milk. I am glad to find in Dr. Burney Yeo’s " Manual of Medical Treatment"that he has recommended a salted alkaline milk drink in acute rheumatism. Clinical observation has, however, suggested to me another line of diet, the further trial of which I may safely invite. A temporary vegetarian diet seems to be as much indicated by the rheumatic state as the avoidance of animal food, and in refractory cases it is possible that the administration of soups made of a variety of vegetables such as I am now prescribing at St. George’s Hospital supply the food as well as in part the medicine required. Whilst meat renders urine acid, vegetables render it alkaline, and this is the result at which we aim.

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