CHAPTER Xn.
CONSTITUTIONAL DISEASES.
Arthritis Deformans.
Remember that this is an affection in which pro- found changes occur in the joint, and these changes are not only chronic, but progressive.
Remember that in this condition there is no uni- formity in the mode of onset. Some cases have an acute onset, with fever; red, swollen, and tender joints, so closely resembling acute rheumatism that a positive diagnosis will be impossible during this stage.
Remember that in acute rheumatism the tendency is to a complete restoration of the joint function, while in arthritis deformans the tendency is always toward joint destruction, and each attack further impairs the action of the joint.
Remember that the small joints of the hand and feet are the first to be attacked.
Remember that in an acute attack, pain, limita- tion of movement, and swelling of the joints are present. The intensity of the pain is of no aid in prognosis. First, the characteristic of the pain is that it is spontaneous, coming when the joints are at complete rest; often made worse by the warmth of the bed. Second, it is not shifting like that seen in rheumatic fever. Third, muscular cramp, due
260
ARTHRITIS DEFORMANS. 261
to the spasmotic contraction of the atrophied mus- cles, thus increasing tension and pressure on the inflamed joint.
Remember that swelling is a very early manifes- tation of the disease. The swelling is fusiform, due to the thickening of the capsule of the joint. The atrophy of the intervening muscles causes the fusi- form appearance of the joints to be more pro- nounced. The large as well as the small joints show this fusiform appearance.
Remember that muscular atrophy occurs in all cases, and is marked by its progressiveness, advanc- ing pari passu with the joint lesion- Remember that in many cases the axillary and in- guinal glands are swollen.
Remember that the pigmentation of the skin is a prominent sign in many cases. It occurs on the fore- head, temples, face, and neck. The tints vary, but the most common are lemon, orange, or citron color. The patches have a luster varying with the angle of reflected light.
Remember that a rapid pulse, having no relation to the fever, is of considerable value in diagnosis.
Remember that the symmetry of joints involved is very significant, while the large number of joints involved and the absence of any tendency to casea- tion exclude tuberculosis in the diagnosis.
Remember that Heberden's nodes, when present, are found on the sides and ends of the distal phalanges, especially of the fingers, but sometimes
262 CONSTITUTIONAL DISEASES.
of the toes. When found, they are of prognostic value, as the large joints very rarely become in- volved, and these nodosities are said to be promises of long life.
Remember that joint distortion is characteristic, and due to exostoses or outgrowths of bony sub- stances that lock the joint.
Treatment.
Rest during an acute attack is imperative, and, owing to rheumatic simulation at this stage, the salicylates should be given.
Massage should not be attempted with an acutely inflamed joint, but it is clearly indicated after this subsides. When carefully and perseveringly carried out, it is beneficial.
Diet. Plenty of good, nourishing diet should be given. There is not an article of diet that is known to aggravate it.
Baths. Hot baths are excellent and a course at Hot Springs, Arkansas or Virginia, will often be very beneficial.
Medicinal. Fowler's solution of arsenic, given in 3 to 5-drop doses, has given good results in some cases. Guaiacol carbonate gr. v-gr. xv daily and rapidly increased gives good results, and its good effect, as well as that of arsenic, appears to be en- hanced if an iodid be combined. The iodid of iron may be given, or a saturated solution of sodium iodid, 10 to 15 drops in milk, an hour after meals.
ARTHRITIS DEFORMANS GOUT. 263
Superheated air to the affected joints by means of a hot-air apparatus gives good results in many cases.
Gout.
Remember that gout is a nutritional disorder, and the arthritis is due to the deposit of sodium biurate from the blood, which is surcharged with an excess of uric acid.
Remember that the use of fermented liquors and little exercise is responsible for a large majority of the cases.
Remember that gout and arteriosclerosis usually coexist.
Remember that the following are the premonitory signs of an attack of acute gout : twinges of pain in the small joints of the hands or feet, restlessness at night, irritability of temper, and dyspepsia, with scant, highly colored and acid urine that deposits urates on cooling.
Remember that the announcement of the onset is by severe, vise-like pain, occurring in the metatarso- phalangeal articulation of the big toe — most com- monly the right. The attack is usually nocturnal, gradually subsiding with approach of day. The joint swells rapidly, the tissues become edematous, and the skin is hot, tense, and shiny. Fever is present.
Remember that the subsidence of the attack by morning, to recur again on the succeeding night, is markedly characteristic of acute gout.
264 CON'STITUTIONAL DISEASES.
Remember that, notwithstanding the swollen, edematous condition of the joint, it never goes on to suppuration, but gradually subsides and the skin desquamates.
Remember that the deposit increases with each succeeding attack until the joint is swollen, irregu- lar, and deformed.
Remember that the urates are deposited in the cartilages of the ears, along the tendons, and in the bursse, and may be felt as tophi in the ears.
Remember that severe cramps in the muscles of the calf, abdomen, or thoracic regions occur in the chronic form.
Remember that in gouty subjects severe gastro- intestinal catarrh, with pain and diarrhea, migraine, sciatica^ and various other neuralgias, often take the place of the ordinary acute type.
Burning sensation and itching of the feet at night, and skin lesions, such as eczema, is a frequent com- plaint of patients with gouty diathesis.
Remember that the family history and occupa- tion are exceedingly important factors in arriving at a diagnosis.
Remember that there is a moderate leucocytosis during an acute attack of gout.
Remember that there are some conditions closely allied to gout, but are classed as lithemia. There are various symptoms grouped under this heading, as indigestion, vertigo, headache, nervous irritabil- ity, tingling and a sense of numbness, and a slow
GOUT. 265
pulse, with increased tension and a sharp accentua- tion of the aortic second sound.
Treatment.
Acute Attack. The first thing to be done is to re- lieve the pain. The extremes of temperature — cold and hot — should never be applied; necrosis is thus encouraged. The joint should be kept quiet and wrapped in cotton or compress wrung out of water at the room temperature, or gauze out of the following solutions may be applied: equal parts of chlorofom and olive oil, or oil of gaultheria, to which may be added the tincture of opium in the ratio of 1 to 10. The following is good:
IJ Tincturse opii 3 v
Olei gaultheriae 5 j
Chloroformi 5 iss
Misce et fiat solutio.
Sig. : Paint the joint several times daily. Shake well.
Or:
IJ Estracti belladonnae gr. xlv
Extract! opii gr. v-gr. xv
Unguenti ichthyolis, 10-percent. . . . 5 j
Misce et fiat unguentum.
Sig.: Apply two times daily.
Or gauze out of a saturated solution of Epsom salts applied locally.
Medication. Colchicum appears to be the favor- ite, but should be administered cautiously, and should not be continued indefinitely. The active principle, colchicin gr. %oo-gr. Vso, combined with codein phosphate gr. ^, administered every one or
266 CONSTITUTIONAL DISEASES.
two hours until diarrhea, nausea, etc. — the symp- toms of poisoning — when it should be administered less frequently, is excellent. The bowels should be opened freely with saline laxative. Potassium iodid in stubborn cases is good.
IJ Potassii iodidi gr. Ixxv
Tincturse colchici 3 iiss
Aquse destillatse § v
Sig. : Tablespoonful in glass of water after meals.
Sodium salicylate is preferred by many in 15-grain doses four times daily to adult man.
For the uric acid condition, as well as chronic gout, that medication which will assist in holding urates in solution is the best. The disodium phos- phate appears to be the important element in dis- solving urates, and the administration of calcium salt, preferably the carbonate, protects this sodic phosphate and thus assists in the solution of the urates. This may be prescribed as follows:
IJ Calcil carbonatis gr. x
Lithii carbonatis gr. j
Colchieini gr. 1,^qq
Pulveris aromaticse gr. x
Misce et fiat pulvere No. I, Dentur tales doses No. L.
Sig.: Powder every three hours in acute conditions; three times daily in chronic or lithemic conditions.
These patients must drink plenty of water, whether it be acute or chronic condition. The alka- line mineral waters are best.
Exercise must be taken, even in acute cases, just as soon as they are able to be up.
Diet. Most of these patients eat too much. The
GOUT DIABETES MELLITUS. 267
amount of food should be reduced. Plenty of fresh vegetables and fruits should be taken. Meats are allowable. Fats and carbohydrates should form a large part of the diet, especially the fats.
Lithemic patients should be given potassium iodid at intervals to assist in elimination.
Diabetes Mellitus.
Remember that not all cases which show sugar in the urine* are diabetics. The following three factors must be true in all cases of diabetes :
The form of sugar in the urine must be grape sugar.
It must be found for a long period of time — for weeks, months, or even years.
The excretion of sugar must take place after the ingestion of a moderate amount of carbohy- drates.
Remember that a slight trace of sugar is common in obese persons.
Remember that the two important etiologic fac- tors that produce diabetes are:
Pronounced nervous derangement; either func- tional— as worry, mental shock, or some severe ner- vous strain; or organic lesion — as disease of the spinal cord or brain, or injury in the region of the floor of the fourth ventricle.
Disease of the pancreas, leading to the destruc- tion of the cells of the islands of Langerhans — most frequently caused by chronic pancreatitis, and it is
268 CONSTITUTIOXAL DISEASES.
throTigli this condition that gallstones become an etiologic factor. Remember that urinalysis reveals:
Large increase in the amount of urine for twenty-four hours.
High specific gravity.
Pale color and sweetish odor.
Acid reaction.
Sugar is present.
Albumin usually.
Remember the diabetic tabes — a peripheral neuri- tis, with lightning pains in the legs and loss of knee- jerk. The patient has the ^'steppage gait" seen in arsenical and alcoholic neuritic paralysis.
Remember that a patient complaining of exces- sive thirst, inordinate appetite, and frequent mictu- rition calls for an examination of the urine for sugar.
Remember that the tongue is dry, glazed, and red, and the mouth is dry. The gums are swollen, and constipation is the rule. The skin is dry, no sweat- ing unless coexisting phthisis be present, furuncu- losis is common, and general pruritus may be very distressing.
Remember the coma that develops in these cases, due probably to acetone, and usually terminates fatally.
Remember that fraud is often practiced, and cane sugar has been found in the urine.
Remember that gangrene may occur, due to arteriosclerosis.
DIABETES MELLITUS. 269
TrEATMEjSTT.
Diet. The first thing is to determine the amount of sugar excreted. The next step is to cut off all forms of carbohydrates and try to render the pa- tient aglycosuric. The following outline will assist:
Breakfast. Tea or coffee, § vj ; beefsteak or mut- ton chops without bone, or boiled ham, o iv ; one or two eggs.
Lunch. Cold roast beef, 5 vij ; celery, fresh cucum- bers, or tomatoes, with vinegar and olive oil, 5 ij ; pepper and salt to taste; water, 5xv; coffee, §ij, without milk or sugar.
Supper. Clear bouillon, § x; roast beef, § vij; but- ter, 5 iij ; green salad, 5 ij, with vinegar, 3 ij, and olive oil, o vj ; water, § xv.
One or two raw eggs may be given at bedtime and water, § xv.
The amount of sugar in the urine will drop, but, should a small amount continue, it is best then to have a ' ' fast day, ' ' when the patient takes no nourishment for twenty-four hours, when it will be found that the patient is not excreting sugar. The diet should be carefully arranged for each indi- vidual case.
Skin. Baths should be taken frequently. Warm, or even cold if the patient is robust. Some carbol- ized soap should be used to wash the skin. Flannel should be worn.
Light exercise or massage should be used, and all worry should be avoided and a quiet, even life lived.
270 CONSTITUTIONAL DISEASES.
The alkaline mineral waters should be used freely. From 3 to 6 ounces of Vichy may be drunk half an hour before each meal, or Apollinaris may be ordered in much larger quantities.
Medicinal. Opium is the only drug that is worthy of trial. It should be borne in mind that diabetics have a great tolerance for it. Codein may be used, and, as it is less constipating, is preferable. Codein in Yo-grain doses should be given three times daily and gradually increased until 4 or 5 grains are taken.
Opium may be exhibited in many ways, as:
B Extract! opii gr. xv
Extract! gentianse q. s.
M!sce et fiat massa. Divide in pilulse No. XXX. Sig.: 3 to 12 pills daily.
Or:
IJ Extract! opii gr. ss-gr. j
Extract! belladonnse gr. S3
Sacchari lactis gr. v
Misee et fiant pulveres, Dentur tales doses No. XXV.
Sig.: 3 powders daily.
Arsenic is very useful in many cases. It may be added to either of the above mixtures, or, better, it, may be given as Fowler's solution, gradually in- creasing the dosage until saturation.
Coma. There is nothing that equals venesection and withdrawal of blood, and replacing it with a 1 or 2-percent solution of sodium bicarbonate in nor- mal salt solution ; 1 or 2 pints may be run into a vein every three or four hours if necessary. As a rule,
DIABETES MELLITUS. 271
this is only a temporary relief, and there is recur- rence and death.
Remember that by administering sodium bicar- bonate at frequent intervals it may be possible to postpone an attack of coma, which is an acidosis.