Part 41

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GENERAL PARESIS.--Wine, worry and women produce a great many cases of this disease. The doctors claim a notorious criminal now committed to one asylum and about whom we have read so much, is a victim of this disease.

First stage.--There is worry, anxiety, sleeplessness and melancholy.

Second stage.--Stage of mania, wealth, power, and grandeur, alternating in some cases with attacks of temporary depressions.

Third stage.--Patient passes into a condition of subacute or chronic mania, with a slow tendency to decadence of all the powers, idiotic.

Fourth stage.--Stage of physical and mental failure and of death. Syphilis causes most cases. It usually develops between twenty-five and fifty years. The outlook for such cases is very unfavorable, as the patient usually dies from one to eight or ten years after the beginning of the disease.

TREATMENT.--There have been great advances made in recent years in the treatment of persons mentally unsound. They should be placed under proper treatment at an early stage. The causes have been given so that preventive measures may be taken.

CONSTITUTIONAL DISEASES.

RHEUMATIC GOUT. (Rheumatic Arthritis. Arthritis Deformans).--Cause.--It occurs most often from thirty to fifty-five, usually in women, generally at or after the change of life, and most frequently in those who have not had children. The involvement of the joints is most common in adult males.

Exciting cause may be: Exposure to cold and wet, improper food, unhygienic surroundings, worry, blows and acute infections.

Conditions.--Several joints are usually involved symmetrically. At the edge of the joints there is formation of new bone covered with cartilage, causing the enlargement of the bone and often partial loss of motion in that joint.

Symptoms.--Several distinct types exist. 1. General progressive types which may be acute or chronic.

Acute.--This occurs usually in women from twenty to thirty and at the change of life. It comes on like acute joint rheumatism, many joints being affected, permanent enlargement appearing early, redness of the joints rarely existing, the pain being very severe, some fever, feel very tired, with anemia, loss of flesh and strength. The first and later attacks are often associated with pregnancy, confinement or nursing.

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Chronic Type.--There is a gradual onset of pain or stiffness in one or more joints, usually of the fingers, then of the corresponding joints of the other side and then other joints. The swelling at first may be in the soft parts of the joints with effusion in the joints and tenderness. The pain varies from slight to severe. Periods of improvement and getting worse alternate; the joints becoming enlarged and deformed, often nearly stiff in partial bending on account of the thickened bone and soft tissues. The muscles that move the joint dwindle and there may be changes in the skin and nails of the parts affected due to the want of proper nourishment. Disturbances of the stomach and anemia are common. The heart is not affected. There may be only a few joints affected, or many, with great deformity, before the disease reaches the period of inactivity.

2. Monarticular or one joint type.--This usually occurs in males over fifty; one joint or a few large joints may be affected, generally with shrinking of the corresponding muscles. If it occurs in the hip it is called Morbus Coxae Senilis,--Hip joint disease in the aged.

Recovery.--The disease usually goes on with intervals of improvement and often results in great crippling and disability. In some cases it becomes permanent.

General Treatment.--The climate should be warm and dry. The patient should avoid exposing himself; lead a general hygienic life, with as nourishing food as his digestion will permit. The chief line of treatment should be to improve the general health and relieve the pain. The stomach, bowels, and kidneys should be kept working well. Nourishing food should be taken, but its effect must be watched. Cod-liver oil to build up the system, iron and arsenic may be of value. Sometimes iodide of potash is good. Early and thorough treatment at Hot Springs offers the best hope of arresting its progress, the Hot Springs in Bath County, Va., and in Arkansas. Much can be done at home by hot air baths, hot baths, and compresses at night to the tender joints.

Local.--Massage carefully given is helpful. The hot air treatment is good. Baking the joints is now frequently done.

GOUT (PODAGRA).--A disorder of nutrition characterized by excess of uric acid in the blood, attacks of acute arthritis (inflammation of joints) with deposit of urate of sodium in and around the joints; with various general symptoms.

Causes.--Heredity; male sex, usually appears from thirty to fifty and rarely under twenty; from continued use of alcoholic liquors, especially fermented, with little or no exercise; too much meat. Unhygienic living with poor food, and excessive drinking of ale and beer may be followed by the "poor man's gout." It is common in lead workers.

Symptoms. Acute Type.--There is often a period of irritability, restlessness, indigestion, twinges of pain in the hands and feet; the urine is scanty, dark, very acid, with diminished uric acid and deposit when it is cooled. The attack sets in usually early in the morning with sudden intense pain in a joint of the big toe, generally the right; less often in an ankle, knee, wrist, hand or finger. The part swells rapidly, and is very tender, the overlying skin being red, glazed and hot. The patient is usually as cross as a wounded bear. The fever may be 103. The pain may subside during the day, and increase again at night. There is no suppuration (pus forming). The symptoms usually decrease, gradually, the entire attack may last from five to eight days. Scaling of the skin over the sore part may follow. After the attack, the general health may be improved, and the joint may become normal or but slightly stiff. It recurs at intervals of a few months commonly.

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Retrocedent Gout.--This is a term applied to serious symptoms which sometimes go with rapid improvement of the local joint conditions. There are severe pains in the stomach, nausea, vomiting, diarrhea, pain in the heart, difficult breathing, palpitation, irregular and feeble action of the heart with brain symptoms, probably from uraemia. These attacks often cause death.

Chronic Gout, Causes, etc.--Frequent acute attacks; many joints, beginning with the feet, become stiff and deformed, perhaps with no motion. The overlying skin may ulcerate, especially over the knuckles. Dyspepsia, arterio-sclerosis, enlargement of the left ventricle of the heart and a great quantity of urine with low specific gravity are common. The patient is morose and irritable. Eczema, chronic bronchitis, frequently complicate the case.

Death often occurs from uraemia, meningitis, pleurisy, pericarditis or peritonitis.

Treatment, Preventive.--Live temperately, abstain from alcohol, eat moderately, have plenty of fresh air and sunshine, plenty of exercise and regular hours. These do not counteract the inherited tendency. The skin should be kept active, if the patient is robust, by the morning cold bath with friction after it; but if he is weak and debilitated, the evening warm bath should be substituted. The patient should dress warmly, avoid rapid alternations in temperature, and be careful not to have thc skin suddenly chilled.

Diet in Gout.--Most persons over forty eat too much. Eat reasonably and at regular hours and take plenty of time to eat. Do not eat too freely of meats and avoid too much starchy and sugary foods. Fresh vegetables and fruits may be used freely, except cranberries and bananas.

Dr. Osler of England says.--While all stimulants are injurious to these patients some are more so than others, particularly malted liquors, champagne, port and a very large proportion of all the light wines. Take large quantities of water on an empty stomach, mineral waters are no better than others, but treatment of chronic and irregular gout at springs gives the advantage of regular hours, diet, etc.

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Diet from a prominent hospital for gout patient:--

May Take--

Soups.--Fresh fish soups, vegetable broths clear.

Fish.--Raw oysters, fresh fish, boiled.

Meats.--Fat bacon, boiled or broiled chicken, game (all sparingly).

Farinaceous.--Cracked wheat, oatmeal, rice, sago, hominy, whole wheat bread, or biscuits, rye bread, graham bread or rolls, crackers, dry toast, milk toast, macaroni.

Vegetables.--Mashed potatoes, green peas, string beans, spinach, cabbage, cucumbers, cresses, lettuce, celery.

Desserts.--Plain milk pudding, junket, rice and milk, sago and milk, stewed fruits, all without sugar.

Drinks.--Weak tea (no sugar), milk, buttermilk, toast water, pure water, cold or hot.

Must Not Take--

Veal, pork, goose, duck, turkey, salted, dried, potted or preserved fish or meat (except fat bacon), eels, mackerel, crabs, salmon, lobster, eggs, rich soups, gravies, patties, tomatoes, sweet potatoes, asparagus, mushrooms, rhubarb, lemons, pickles, vinegar, fried or made dishes, rich puddings, spices, pies, pastry, sweets, nuts, dried fruits, tobacco, coffee, cider, malt liquors, sweet wines, champagne.

Treatment.--In an acute attack raise the affected limb and wrap the "sick" joint in cotton wool; warm fomentations may be used. The wine or tincture of colchicum in doses of twenty to thirty drops may be given every four hours in combination with the citrate of potash, fifteen grains, or the citrate of lithium five to ten grains. Stop the tincture of colchicum as soon as the pain is relieved and then you can give wine of colchicum ten drops every four hours, watching for irritation of the stomach, bowels and kidneys.

Dr. Hare of Philadelphia says.--For hospital practice a very useful mixture is made by adding one part of bicarbonate of sodium to nine parts of linseed oil. The joint is then wrapped in a piece of lint soaked with this concoction. In some cases oil of peppermint has been recommended. In chronic gout Dr. Hare also gives for diet milk and eggs, the white meat of chicken; fruits, cooked without sugar being added, are allowed. Tea and coffee being used only in moderation. If any wine is taken it must be followed by copious draughts of pure water and the last article should be used ad libitum. On the other hand, pastries and, more than all, sweet wines, are the worst things that such a patient can take, and must be absolutely prohibited.

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RHEUMATIC FEVER (Articular Rheumatism).--Causes. This may be acute or chronic. It is an infectious disease characterized by inflammation of several joints. The joints are held in place by ligaments and are inclosed by a thin membrane. In this acute rheumatism these parts become congested and inflamed, there is redness and swelling, heat and pain. Fluid is passed into the joint sometimes and then the parts look watery (oeclematous). The inflammation and swelling cause great pain in the joint.

Predisposing.--A damp climate, winter and spring, young adults and persons who are exposed to damp, wet and cold.

Condition.--There is congestion of the soft parts of the joints and effusion into the joint cavities of a watery fluid. Endocarditis, pericarditis, myocarditis, pleurisy and pneumonia may complicate it. The first named, endocarditis, is very common and as the mitral valves become inflamed it is likely to leave valvular trouble unless carefully watched and treated at the time.

Symptoms.--The invasion may be gradual, with a very tired feeling and often tonsilitis; but it is usually sudden, with pains, soreness in one or more joints and fever. The knees, ankles, elbows and wrists are much affected, but it frequently goes through almost every joint in the body and sometimes repeats the terrible dose. I know, for I had it twice. The suffering, torture and pain sometimes are simply indescribable and almost too hard to bear. The joints become hot, red, painful, swollen and tender to touch and motion. It seems to hurt worse when anyone comes near, for the patient is afraid of careless handling.

Fever.--This runs from 102 to 104 and is modified by profuse perspiration with bad odor and, generally, it does not afford any relief. The urine is very acid, very thick and looks like thick, strong coffee. The symptoms frequently disappear partially from one joint or joints as they begin in other joints, attacking several in rapid succession, the fever varying and changing with the degrees of joint involvement.

We may see the shoulder and hip, the elbow and wrist, knee and ankle, etc., all affected at once: Heart complications are frequent and bear close watching, for they are dangerous to life and the future health of the patient. The patient becomes very anemic and this progresses rapidly. When improvement does begin it is gradual; or the disease may become chronic. Care must be taken not to be too active when improvement sets in or you will cause a return by using the joints before they have become thoroughly well. I did the same thing in my anxiety to get out, but would never be as reckless again. Pain and stiffness of the joints often last long after convalescence has set in. One who has had this disease once is liable to another attack if he is not careful.

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MOTHERS' REMEDIES. 1. Articular Rheumatism.--A gentleman sends us the following treatment for articular rheumatism and writes as follows: "I send you the following treatment for articular rheumatism because I used it myself and was cured in a very short time, in fact, about ten days. It was a number of years ago in the early spring when my knee joints, ankles and wrists began to pain me and continued to become worse for about a week, at the end of which time both my knees were perfectly stiff. I sent for my physician; he wrapped my knees with common baking soda; taking long wide bandages he was enabled to have the baking soda a fourth of an inch thick around the knee, raising the bandage as he laid the soda on; after this was completed I had heavy wet hot cloths laid around my knee and renewed every fifteen or twenty minutes for probably eight or ten hours. In the meantime I was taking the salicylate of soda and the cathartic, veronica water, as directed below. The following day I sat up with my legs resting on a chair, straightened out, and hot flat irons at my knees. I began this treatment on Saturday, and the following Thursday was able to walk about and go out of town, and never had rheumatism since, but at two or three different times I suspected it was coming on and used the salicylate of soda and veronica water as a successful preventive; at least the rheumatism did not materialize.

Veronica Water.--Dose:--Glassful every two and one-half hours till bowels are free, then one dose a day.

Also Salicylate of Soda 1 ounce Water 6 ounces

Large teaspoonful every two hours with a quinine pill every other dose."

2. Rheumatism, Cotton Excellent for Inflammatory.--"Take a roll of cotton batting and wrap the limb, or part of the body affected, as firmly and tightly as possible, without tearing the cotton, let it remain "twenty-four hours, then tighten it up by unwinding and rewrapping the cotton as tight as possible, as on the first application, and so continue every twenty-four hours until cured, which, in my case, was three days. I had been troubled with rheumatism for a long time, and was unable to walk. I tried everything, doctors and all, but nothing helped me. A lady from Cincinnati, who was visiting at a neighbor's, called at my house one day and learning what was the matter with me, advised me to put cotton on as stated above. I had no faith in it, but I had tried everything else and concluded I would try that, with the result that it cured me. Possibly if a case should require a longer time for a cure than mine it might be necessary, or be better, to replace the cotton with a fresh roll. The rewrapping every twenty-four hours is intended to keep the cotton batting firmly and tightly around the part affected as the swelling recedes."

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Prevention.--Wear flannel late and early. Keep from taking cold. Put off wet things of every kind immediately upon getting home and dry your body and put on dry well-aired clothes. Never sleep in a damp bed, under damp unaired clothes. When you go away from home do not sleep in a room or bed that has been unoccupied for any length of time, especially if there is no furnace in the house. Do not sit down in wet damp clothes, stockings, shoes, etc. Do not sit down anywhere to "cool off." It is inviting trouble and sickness. Do not lie on the damp ground, do not sleep on the first floor of an old damp house. Have plenty of sunlight and air in your sleeping room. These directions apply to the chronic cases also. It does not matter so much if one is wet or sweating as long as he keeps moving or working. On wash day do not dry your clothes in the kitchen or sitting room, or put them on your bed, unless they have been thoroughly dried, aired and warmed before using. These little things mean much in real life.

PHYSICIANS' CAUTION for Articular Rheumatism.--Go to bed and remain there and do not get up too soon, for remember the parts are still tender when they may not be painful.

Local Treatment.--1. There must be absolute rest. Remove the sheets from the bed and wrap woolen cloths or blankets about the patient and protect the inflamed joints from the weight of the coverings. Cover the joints with gauze or absorbent cotton, after putting on the parts a thick coating of ichthyol ointment.

2. Sometimes hot fomentations are helpful in relieving the suffering; sometimes cold cloths are best.

3. The following is good. Apply with cloths wrung out of it:

Carbonate of Soda 6 drams Tincture Arnica 10 ounces Glycerin 2 ounces Water 9 ounces

4. Oil of Wintergreen 1 ounce Compound Soap Liniment 8 ounces

Mix.

Rub the affected parts with oil of wintergreen and then wrap the parts in cotton wool and soak with the solution.

5. "A layer or two of gauze saturated with methyl-salicylate is wrapped around the painful joints and covered with paraffin paper, or other impervious dressing, held in place by a bandage. This is renewed once or twice daily until the pain in all the joints is relieved."

6. Internal.--Sodium salicylate or aspirin given until the pain and temperature are relieved; usually five to ten grains of sodium salicylate every three hours for an adult; or five grains of the aspirin every three hours.

7. Dr. Hare recommends for the beginning in a strong, healthy individual, ten drops of the tincture of aconite at once in a little water, and follow it by a teaspoonful of a mixture containing fifteen drops of tincture of aconite and two ounces of water everyone-half hour, until perspiration on the skin betokens the circulatory depression through the action of the drug. I use aconite in this disease very often, but not in such doses as the first one. It seems to me that it is uselessly large. I use about one-tenth of a drop at a dose everyone to two hours during the first twenty-four hours.

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Nursing.--The nurse must have the patience of Job to attend a patient sick with this disease; but you must remember the suffering is awful. The patient may be very restless and the pillows may need rearranging every few minutes. Also be careful how you handle the patient. It hurts terribly to be even touched. A rough, hearty person has no business to care for such a patient. I allow patients to say anything they wish, for this is a painful disease. They may swear at me if they wish. I know how it is, for I was there twice, the last time for six long weeks. Have patience and courage and cheer your patient. Do not look cross or scold.

Diet.--Milk mainly, broths, gruels, albumen water, oyster or clam broth, milk toast, buttermilk, kumiss. Do not give solid food. Water, lemonade, vichy or carbonated water.

CHRONIC RHEUMATISM.--Causes.--Heredity may predispose to it. It is most common in those who are exposed to hard labor in the cold and wet; especially in women about middle age. It occasionally follows sub-acute, but rarely acute rheumatism.

Symptoms.--Many large joints are usually affected; sometimes it may be only one joint; at times, the small joints only are affected. It may be only on the one side. It usually persists in the joints involved, but may attack others. The chief symptoms are stiffness of the joints, especially after a rest and this diminishes after some motion, also pain, which grows worse in damp weather. The joints may be tender to the touch, slightly swollen, rarely red. They may in time become entirely stiff and deformed. The general health may be good or there may be anemia, dyspepsia and valvular disease due to sclerosis,--hardening of the valves of the heart.

Prognosis.--This is good as to life, but the disease is often progressive.

Treatment. Preventive.--A warm, dry, unchangeable climate, good surroundings, good food; keep the stomach and bowels and kidneys in good condition, avoid taking cold. Do not sit down in a draft to "cool off." Do not go into a cool room in summer when you are warm or sweated. Do not sleep in a bed that has not been used for months and kept for "company." Do not dry your clothes in the kitchen and in that way make the whole house steamy and damp. Do not sleep under unaired damp covers or in a damp night dress. Always air and dry your bedding and night dress before using. Do not take a hot bath and go into a cool room to cool off, but wrap yourself up so as to be warm and cool off gradually. Any additional cold will cause more rheumatism.

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Sleeping rooms on the first floor are an abomination for rheumatic persons. Do not sit down in wet clothes, stockings or shoes. Take them off immediately on getting home, wipe yourself dry and put on dry garments. Care in such little seemingly foolish things will do wonderful things for a rheumatic person. I had two rheumatic attacks in my first year of practice. Since then I have learned caution and through a hard and busy life I have kept myself reasonably well by looking after such little aids and cautions as, the above. I never sit down for any length of time in damp or wet clothes, and if I can do that, persons that are not driven like doctors can do the same. These cautions apply to not only this kind of rheumatism, but to all kinds of rheumatism, neuralgias, and to inflammatory diseases, such as neuritis, tonsilitis, pneumonia, pleurisy, etc. Hot air baths, Hot Springs, massage will be more effectual in this disease than in the former. Iodide of potash also is very useful. Flannel underwear, heavy and light weight, is very beneficial in rheumatism. Great benefit can be derived at home by wrapping the affected joints in cold cloths, covering with a thin layer of flannel and protected by oiled silk. A great many cases are helped by using hot fomentations of hops, wormwood, smartweed, etc. Turpentine applied locally to the joints is effective, but it is very likely to injure the kidneys when used freely and in these days when there are so many diseases of the kidneys one must be careful or they will produce an incurable and serious disease in the place of one that is painful, but not necessarily dangerous. Many of the simple remedies have a good effect on the rheumatic troubles.

PHYSICIANS' TREATMENT for Rheumatism.--Dr. Hare gives the following to rub on large joints: