TREATMENT 257 



frequently described (Poncet, Maillard, H. Strauss, Barjon, Eoma, Potal). 

 The usual course of such cases is this : the disease begins as a subehronie or 

 chronic articular rheumatism which finally becomes localized to one or more 

 joints, and there develops typical tuberculous changes. This course resembles 

 osteomyelitis, of which we observed a case in the clinic at Basel in an indi- 

 vidual aged seventeen, in whom, after a fever lasting several months, accom- 

 panied with wandering multiple joint swellings, muscular contractures, and 

 exostoses, the epiphyses became loosened from the neck of the left femur, 

 thus confirming the diagnosis. 



True chronic polyarthritis may owe its origin to various infections, or to 

 constitutional causes of the type suggested by Lancereaux and Bouchard. 

 Perhaps in some cases nervous disturbances may play a role. These cases 

 cannot be diagnosed by rules, no matter how skilful the reasoning processes, 

 but only by following the advice given by Archibald Garrod, to inquire into 

 the family history of each individual case, its nervous disturbances, etc., and 

 by carefully investigating the bacteria present. Perhaps in this manner a 

 rational differentiation of the varying forms, which to-day is impossible, may 

 in time be attained. 



TREATMENT 



As in all chronic diseases for which we have no specific, the number of 

 remedies is legion. But^ in giving a synopsis, I shall divide them into 

 groups. 



First, internal remedies. I take for granted the knowledge that the anti- 

 rheumatics, the salicylates, antipyrin and allied remedies often diminish pain, 

 but never have the specific action which is the case in acute articular rheuma- 

 tism. The salts of iodin are very useful, not only in gonorrheic and syphilitic 

 rheumatoid, but also in the exudative polyarthritic form. Tonics are advised 

 by the best authorities, and since experience has shown that in these affections 

 the local difBculties are closely related to the general health of the patient, 

 cod liver oil, iron, arsenic, quinin and strychnin preparations are of decided 

 benefit in anemic, feeble, emaciated individuals, especially after febrile parox- 

 ysms or after active treatment. The salts of lithia, and mineral waters 

 containing lithia, have been advised on account of their action in gout, but 

 there is no rational indication here for their use. In fact, in a disease in 

 which excessively chronic and decided yet spontaneous changes occur, the 

 value of any curative agent is always very uncertain. 



Menzer's successful trials of streptococcus serum, which were based upon 

 the theory of an infectious etiology, are interesting but by no means con- 

 clusive. 



The principal role in therapy is played by external physical remedies. 



Water must be mentioned first. That energetic applications of cold water 

 are harmful in the first stages of inflammation is a common experience. 

 Only after acute exacerbations have run their course, and after long continued 

 sweating procedures, may cold douches, needle baths, and affusions be made use 

 of by an experienced and careful hand, and then serve a useful purpose as a 

 hardening process. 

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