The Treatment of Acute Rheumatism, illustrated by cases taken
from private practice. By Geo. L. Upshur, M.D., Norfolk, Va.,
Member of the American Medical Association.
Case 1.—Mrs. W., aged 30, of sanguineous temperament, and
rather delicate, was seized with pain in the right shoulder joint
on 23d of September, 1846. The weather had been inclement
for several days previous, and she had imprudently exposed her-
self. I saw her on the 24tb, at which time all the large joints
were somewhat painful, although there was little or no fever.—
Prescription. Jt. Pulv. Dover, gr. xv. Div. in chart. 3. S. one
powder every three hours.
25th. Patient much more uncomfortable ; slept none last night ;
nearly every joint red, swollen, and exquisitely tender ; pulse,
full, hard, and bounding; bowels confined ; tongue foul, thirst
urgent, and perspiration very profuse. Being desirous of avoiding,
if possible, the use of the lancet in so delicate a subject, I ordered
only the following: J&. Vin. Colch. Rad. f.Siss.; Magnes. calc.
5ij.; Magnes. Sulph. ^ss. ; aquee f.giv. M. S. A table-spoonful
every three hours, until it purges freely. At 9 o’clock P. M. the
mixture had produced several copious stools, but without relief to
any of the symptoms ; took 20 ounces of blood from the arm,
26th. Symptoms somewhat improved ; less fulness of the pulse,
much less perspiration, and not so much pain. Quiniee Sulph.
5ss. Div. in chart. 3. S. One powder every three hours.
On the 27th, my patient was so entirely relieved, that I
considered her convalescing, and ceased to visit her after the
28th.
Case 2.—Miss B., aged 19, very large and robust, was taken with
chill followed by high fever, with metastatic pains in the joints
and a profuse warm perspiration, on 14th of January 1847. Sent
for me in the night, and I have never seen a better marked case of
acute articular rheumatism—even the joints of the fingers and toes
were red and swollen. The blood was fairly running riot through
the vessels, and the patient alternately shrieked and ground her
teeth in very agony. I bled her to full 25 ounces, which checked
the perspiration, and lessened the pain in a considerable degree;
ordered gr. x. of Dover’s powder to be taken at once.
15th. Somewhat more comfortable; still suffering very much.
J£- 01. Tiglii gtt. ij.; Saponis Hisp. q. s. M. Pil. 2. S. Give one
pill immediately, and if it does not act in four hours, the
other.
16th. Took both pills which acted copiously ; passed a com-
paratively good night; and is decidedly better this morning ; pills
vomited her freely; ]£. Calomel gr. x. Ol.Tiglii. gtt. iss. M. Pil. 3. S.
one pill every hour.
On the 17th the patient was on the verge of convalescence ;
ordered ten grains of Dover’s powder at bed-time.
18th. Improving ; opened the bowels with croton oil.
19th. Pain nearly subsided ; no fever ; appetite returning. Or-
dered a table-spoonful, three times a day, of the colchicum mix-
ture, to keep the bowels soluble. On the 24th discharged her
cured.
Case 3.—Mr. E., aged 22, sanguineous temperament, was
seized with acute articular rheumatism, May 16th, 1847; saw him
on 17th ; pain confined chiefly to shoulders, elbows, and wrists,
which were red and swollen. Prescribed croton oil in purgative
doses followed by the colchicum, magnesia, &c. as in other cases.
Discharged him convalescent on the 19th. On the the 6th of Au-
gust following he was again attacked, and again relieved, in a
great degree, by the croton oil. The disease, however, became
chronic in the course of two or three weeks, when I gave him the
vinum colchici, and subsequently the iodide of potassium with the
fluid extract of sarsaparilla, with fine effect; I also derived great
benefit from “ firing” around the joints as recommended by Dr.
Corrigan in the Dublin Hospital Gazette for March 1846. The
article is too long to insert here, but it may be found, condensed,
in vol. 4th of Ranking’s Abstract, p. 102, and is well worth a pe-
rusal.
About four weeks after the disease assumed the chronic form,
there appeared upon the extremities, a pustular eruption, resem-
bling very closely, the eruption of small pox. The base of the pus-
tules, however, instead of being red as in variola, was livid and
variegated, putting one in mind of the blotches seen in secondary
syphilis. I have no doubt but that there was a syphilitic taint in
this case. After two or three months, Mr. E. returned to his friends
in New England, much improved, but not entirely relieved. I have
not heard whether he ever permanently recovered.
Case 4.—Mrs. Wiles, a very delicate lady, aged 25, mother of
two children, and withal a confirmed dyspeptic, was taken sick
with acute rheumatism in its severest form, May 29th, 1847.
When I saw her on the 30th, her fever was high, the pulse fre-
quent without fulness, perspiration profuse, bowels confined, and
pain in the joints unbearable. Purged her violently with croton
oil, and on the next day, 31st, gave Ji. of Pulv. Jal. Comp., which
acted well.
June 1st. Much better ; fever, pain and perspiration greatly
lessened ; determined to give the colchicum a fair trial. I gave it
to her without intermission, until the 8th, but apparently without
benefit; I then prescribed quinine, ten grains three times a day ;
she took in all sixty grains, and was discharged cured on the 12th
of June, having been ill just two weeks.
Case 5.—Miss M., aged 30, robust, was seized March 28th,
1848, with chill. When I saw her, all her joints were involved,
and there was scarcely a voluntary muscle in the body that could
be moved without pain ; fever high, abundant perspiration, and
constipated bowels; B. 01. Tiglii gtt. vi.; Calomel gr. xxx. M.
Pil. 6. B. Vin. Colch. R. f.3i.; Magnes. Calc. gij. ; Magnes.
Sulph. giij. ; Aqua f.^iv. M. I directed her to take one of the
pills immediately, and after it ceased to operate, to begin with the
mixture and take a table-spoonful every three hours. On visit-
ing her next morning, I was alarmed at her condition. She -was
excessively feeble, pallid, with her extremities cold and shrivel-
led, and passing blood from the bowels every ten minutes ; each
stool being accompanied with violent straining and tenesmus.
The whole abdomen was tender upon pressure ; with nausea, and
a frequent, feeble pulse. With all this, however, she had not even
a remnant of the rheumatism, and could move her limbs about in
any position without the slightest inconvenience.
Upon inquiry, I ascertained that the nurse, a listless, inattentive
creature, had mistaken my directions entirely, by giving the pills
as I ordered her to give the mixture, namely, one pill every three
hours. The patient took six drops of croton oil, and thirty grains
of calomel, within eighteen hours, and, as a matter of course, was
purged nearly to death. The only wonder is, that she did not die
before I saw her. She recovered slowly from the effects of the
hypercatharsis, and has not had a rheumatic pain from that day to
this .’
Case 6.—Frances B., aged 12, lymphatic temperament, seized
Sept. 23d, 1848, with well marked acute articular rheumatism ;
the upper joints chiefly affected, but the disease showing a decided
tendency towards metastasis. Prescribed 01. Tiglii gtt. i. ; Calo-
mel gr. v. M. S. To be taken immediately. The following day
there w7as a decided amelioration of all the symptoms. B- Qui-
niee Sulph. gr. xxx; Div. in chart. 4. One powder to be given
every two hours. The patient was w7ell enough to sit up on the
26th, when I ceased to visit her.
Case 7.—On the 3d of October, 1848, I was called to see Mr.
W., aged 46. He had been in feeble health for a year or two be-
fore, and was then suffering from a chronic ulcer upon the left leg.
For several days he had been troubled with sharp rheumatic pains
in the shoulders and back of the neck. He had very little fever ;
bowels confined. Gave him a table-spoonful of the colchicum
mixture every three hours. The next day he was rather worse,
when I purged him -with croton oil. On the 6th, purged him
again with the same, and again on the 8th, and on the 9th I found
him entirely relieved. In a subsequent attack, I gave him the de-
coction of may-apple (Podophyllum) which acted copiously on the
bowels, and gave him great relief.
Case 8.—Saw William S., aged 40, October 11th, 1848 ; fever,
constipated bowels, and pain, redness and swelling of all the large
joints. Prescribed 01. Tiglii gtt. ij., to be taken at once repeat-
ed the dose the following day, and on the 13th found him so much
relieved that he required no further treatment.
Case 9.—Mr. Hubert S., an athletic young man of sanguineous
temperament, wras seized Nov. 28th, 1848. Three years before, he
had an attack of rheumatism, which confined him to the bed four
weeks. When I saw him, the ankle and knee joints only were
very painful, with now and then a twinge in the shoulders. He
had but little fever, and no perspiration. Prescribed the croton
oil as in the other cases, and repeated the dose on the next day.
The symptoms were relieved entirely, with the exception of slight
pain and stiffness in the right ankle joint. Ordered 5grs. of iodide
of potassium, to be taken four times a day in infusion of hops ;
under this treatment he recovered in about ten days.
Case 10.—Mr. John M., was taken violently on the 8th of De-
cember, 1848. He was a fleshy, muscular man, and suffered in-
tensely. Gave him the croton oil as usual, followed by eight
grains of quinine every hour, until he had taken 40 grains. He
was entirely relieved on the 10th, and had no return of the
disease.
Case 11.—Airs. F., aged 26, recently marrried, anemic and
and feeble, was taken sick on the 18th of January, 1850. Pain,
metastatic, but confined chiefly to the upper joints. She was purged
freely with croton oil every day, until the 21st, when I prescribed
the following. Jfc. Mass. Hydrarg. gr. xx. Quinise Sulph. ^ss. ;
M. Pil. 6. S. One pill every two hours. On the 24th purged
her again with croton oil, and discharged her cured on the
26th.
Case 12.—Mrs. Fanny---------, aged 35, had been suffering from
dyspepsia for more than a year. About ten days before I saw her,
which was on the 18th of March, 1850, she felt considerable pain
in the shoulders, back of the neck, and sides of the chest. Her
bowels were confined, and she had some febrile movement. I
gave her alternately, every day, a drop of croton oil, and fifteen
grains of quinine, for four days. She then took ten grains of Do-
ver’s powder every night, followed by a drop of croton oil in the
morning, until the 24th of March, when she was discharged,
cured.
5 f
Remarks.—A celebrated physician being once asked what he
considered the most successful treatment of acute rheumatism, an-
swered, “ six weeks”—thereby plainly intimating his opinion of
the intractable nature of the disease. While I am ready to admit
that there is some truth in this opinion, and that rheumatism
now and then assumes a form which might well entitle it to a
place among the opprobria medicorum, I am not at all prepared
to entertain the notion, that early and judicious treatment has no
power, in a majority of cases, to alleviate its pangs, or shorten its
duration. On the contrary, I believe that rheumatism is as amen-
able to proper management as any disease of equal severity.
Within the past five years, I have accurately noted the history
and treatment of about thirty cases of acute articular rheumatism,
from among which the twelve cases just detailed are indiscrimi-
nately taken. In these, it will be seen, the average duration of
the disease, was 5j days ; the longest being 14, and the shortest
2 days. Croton oil was used in 11, colchicum in 6, gwimne in 6,
bloodletting in 2, and iodide of potassium in 2. I desire to say
a word or two upon each of these agents.
Of croton oil as a purgative in acute rheumatism, I am prepared
to speak in the highest terms. Cathartics have always stood in
the front rank of remedies in this disease, but I am disposed to
believe that the efficacy of croton oil does not depend entirely upon
its cathartic properties ; it possesses a power over the disease be-
yond these, and apparently not dependent upon them, for other
cathartics, which act as powerfully and as promptly, producing
similar watery stools, do not bring a like amount of relief to the
patient. I do not say that it is a specific, for I am not a believer
in the doctrine of specifics, in medicine; that doctrine has put
more stumbling blocks in the way of medical progress than all the
open quackery of the past half century. I merely desire to state,
that after a fair trial, in a number of cases accurately observed,
where there was scarcely a possibility of falling into error, I be-
lieve that the croton oil is the best single remedy in the treatment
of acute rheumatism ; and I am thoroughly convinced, that it is as
justly entitled to the term specific, in this disease, as is quinine in
miasmatic fever. I speak now, not of chronic rheumatism, nor of
that which results from a syphilitic taint, but of the acute inflam-
matory affection. In all the eleven cases, in which it w?as given,
its beneficial effect -was palpably evident, but particularly as in
cases 5, 6, 8, 10, 11, and 12.
Dr. Wm. A. Thom, an intelligent physician of Northampton
County, to whom I am indebted for the first hint in regard to the
value of croton oil in this disease, informed me, about two years
ago, that he had used it in several severe cases, and uniformly writh
success.
Colchicum has uniformly disappointed me. In cases 1, 4, 7, it
was fairly tried, and although it invariably acted freely upon the
bowels, there was no alleviation of the distressing symptoms. In
the chronic disease, I think I have sometimes derived great benefit
from it, but in the acute form, never. It may be, that I have been
so unfortunate as always to get hold of an inferior preparation,
but some how or other, I have taken the notion, that w’hen a pa-
tient is treated with colchicum only, he would do just as well to
take old Dr. Warren’s six weeks instead.
Quinine I would place next to croton oil in the treatment of
rheumatism. That it is decidedly sedative in large doses, is unde-
niable, and therefore it may be exhibited during the febrile stage.
Given after the use of the lancet, in highly inflammatory cases, or
after powerful purgation with croton oil, it has been productive of
the happiest effects in my hands. I never give to an adult a smaller
dose than ten grains, repeated three or four times a day; less
than this would be worse than useless. It is particularly service-
able in those cases which perspire most profusely.
It seems to me that bloodletting possesses no direct curative
power in the treatment of rheumatism. In robust persons, with
high fever, intense pain, and a full, bounding pulse, I think it sub-
serves a useful purpose in rapidly subduing the over-excited circu-
lation, thus placing the system in a better condition to respond to
the impression of true curative agents. It is true that bloodletting
is one of the most powerful antiphlogistics, and that rheumatism,
in its acute form, presents undeniable evidences of its highly in-
flammatory character, nevertheless it has long since been voted an
inflammation, sui generis, and I believe there is a great deal too
much of the neuralgie about it to justify the heroic use of the lan-
cet so warmly advocated by Bouillaud. Topical depletion has
never been of the least service in my hands, except where the dis-
ease was confined to a single joint, with no disposition toward me-
tastasis.
When the disease assumes the chronic form, or if there should
exist a scrofulous, or syphilitic taint, no remedy will be found
equal to the iodide of potassium. I usually order five grains four
times a day, to be taken in hop tea, the bowels in the meantime
being opened every day with the black draught, or other cathartic.
I have rarely seen the most obstinate cases refuse to yield to this
treatment.
In the second attack of Case 7, almost immediate relief followed
copious purgation wfith the decoction of may-apple (podophyllum,)
but it is very unphilosophical, particularly in so uncertain a science
as Therapeutics, to deduce a general conclusion from a solitary ob-
servation, so I will not venture to recommend the may-apple until
authorized by further trial. I have adverted to it, merely because
it forms a part of the history of the case ; and with the remark,
that it is considered by all of the old negro-doctors in this section
of country as a specific in rheumatism, I dismiss the subject.
Norfolk, Va., Sept. 5th, 1850.