A man has lately been under my care at the Eastern Dispensary, Bath, who nearly a year ago was advised by good medical authority to drink and to bathe in the Bath thermal waters, on account of severe ‘rheumatic’ pain in several of his joints; these pains being always so severe at night as to spoil nearly all sleep. He had, however, never suffered acute rheumatic influences.

When, after a month’s assiduous trial, no benefit was found to result from this plan, he was advised to discontinue using the thermal waters, and to trust to ‘patience’ and ‘change of air’ to restore his health. After nearly a year’s more trouble he applied to me, but even then he did not in the least connect his pain with a syphilitic contagion, which he did not at all deny, though he had never been asked about it. Both knees were slightly swollen, and so was one elbow.

Like several other cases of the same kind, this man was so quickly relieved and seemingly cured by treatment, as to make me protest once more against the lazy intellectual habit of pronouncing every painful joint to be afflicted with ‘rheumatism’.

Use of splints - a caricature of ‘rest’

I cannot too strongly protest against the therapeutic doctrine of ‘rest’ being so caricatured as to imprison a joint in splints for weeks or months at a time; the last hope of rescuing it from permanent uselessness may thus be destroyed.

Intercurrent attacks of inflammation may peremptorily require a joint to be rested; to be placed for a few days on a back splint, to be poulticed, or even mildly blistered; but this is quite a different thing from putting it, whether inflamed or not, into a splint-case or box, and condemning it to a chronic fixed position.

Mistakes in withholding meat or alcohol

Mistakes are sometimes made in the withholding of meat and alcohol, either from an obstinate confusion of ideas between rheumatoid arthritis and gout, or from an ignorance of the real pathology of the former disease.

A lady now under my care had been told by a very eminent physician to live like a ‘child of a year old’, that is, entirely on milk and eggs; and on the same principle she had been forbidden to take malt liquors, or anything stronger than light wines. The result had been unqualifiedly disastrous. There can be no objection to allowing a patient a moderate (and sufficient) quantity of good stout, or Burton ale, or brown sherry; indeed, one or other of these articles is in most cases a necessity.

Sleep and hypnotics

An adequate quantity of sleep is of much moment. We ought also to remember the nutritional value of sound and regular sleep.

I cannot explain the timidity of many medical men in refusing to a patient a necessary hypnotic medicine. They will administer the secondary hypnotics without stint, such as bromide of potassium, henbane, Indian hemp, and hydrate of chloral; but these often entirely fail, and even distinctly disagree.

The case of the lady just quoted is an example of what may happen when morphia is not permitted. She had no sleep for nearly a year; she was nearly worn out with vigils, and her nights were contemplated with dread.

Thinking that morphia must have been tried, and had not been found to agree, I gave her very tentatively one evening a morphia lozenge, which soothed her for an hour; and soon she took four lozenges every evening with remarkably good effect. Ultimately she took a quarter of a grain of morphia in solution at bedtime every night, and three or four lozenges in the early morning hours; and she always awoke very much refreshed, without sickness, headache or constipation.