Fats are an important item in the dietary, and above all other foods or drugs stands Cod-Liver Oil. It should be regarded not as a medicine, but as a food, and, in conjunction with the Extract of Malt, should be given at the termination of every meal. In hereditary cases, where rheumatic or arthritic pains first show themselves in the offspring of parents in whom the disease is well marked, this food or drug should be pushed.
Butter and Cream should also be freely administered, and excess of starchy foods forbidden.
Sometimes an impression has been made upon the disease by a prolonged trial of a purely vegetarian diet, but it is a grave mistake, as pointed out by Garrod, to treat the disease as if it were a form of gout by the routine exclusion of animal food. All dietetic measures which promote bowel, kidney and skin elimination should be advocated, and constipation must he avoided by the use of enough vegetable material.
Every error or departure from the normal standard of health must be carefully sought for, and remedied as soon as discovered. Thus prolonged mental exertion, worry, super-lactation, menstrual disorders, frequent pregnancies and renal disease may be found to be the exciting causes.
The convalescent stages of such affections as influenza and typhoid fever should be treated by prolonged good feeding, rest and change of air in all subjects showing signs of joint trouble.
Open-air exercise except in the worst weather should be practised. There is nothing so deleterious at any stage of the disease, and especially in the early period, as resting indoors. Walking, even when painful, should be perseveringly indulged in, and exercise should be provided for the muscles and joints of the upper extremities by gymnastics or some simple manual occupation as carpentering, but severe strain of the joints must be guarded against. Even when the patient becomes unable to walk he should be advised to spend as much time as possible driving in the open air and sunshine, and when in bed he should be encouraged to freely exercise his legs while lying on his back. Bed in the day-time should be strictly forbidden except in acute cases and in patients wholly crippled; but young subjects who suffer chiefly from the atrophic type of the disease should be encouraged to go to bed at an early hour and to remain there for at least f o hours, as advised by Tubby. The habit of sitting up late
and breakfasting in bed should be strictly forbidden in both the young and old. The question of exercises will be fully considered later on in discussing local treatment.
Drug Treatment.—It would perhaps be difficult to mention any active drug which has not at some time or other been vaunted as a remedy for this obstinate disease. Formerly the class of agents known as alteratives, including Arsenic, Iodine, Guaiacum, Colchicum, Sulphur, Actwa Racemosa and even mercurials were much employed. Later on, Salicylates and their derivatives were extensively used, and as these agents were proving a disappointment the theory of the nature of the affection being a toxaemia arising in the intestines came into acceptance and their reputation revived. The salicylates are thus prescribed because empirically they have been found useful in acute rheumatism, because they act as analgesics, and, thirdly, the less soluble ones are supposed to act as intestinal disinfectants. hence Aspirin, Salol, Benzosalin, Novaspirin and other derivatives which slowly yield free salicylic acid in the intestine are selected for the treatment of rheumatoid arthritis. Beyond the slight relief of pain which they sometimes accomplish their administration cannot b- said to produce any lasting benefit.
Guaiacol has been very extensively employed by Luff (3,00o cases), and he affirms that when administered in sufficient quantity for long periods it arrests the disease, reduces the joint swelling, and relieves pain probably by inhibiting the growth of the specific organisms in the bowel and by neutralising its toxin in the blood and tissues. He gives ro grs. of Guaiacol Carbonate in cachets thrice daily, and slowly increases this to zo grs., which should be continued for at least 12 months, and he recom mends that Iodide of Potassium in solution should be administered in conjunction with the guaiacol carbonate treatment. From similar considerations Bannatyne recommends Benzosol or guaiacol benzoate (ro-gr. doses) and Quinine Salicylate. Saloquinine or its Salicylate (Rheumatin) appears to be preferable to the simple salicylate of quinine.